NCE PRACTICE EXAM

Alzheimer disease is one type of dementia, with a known pre-clinical phase during which pathophysiologic changes begin to occur, followed by a symptomatic phase where cognitive and functional decline becomes noticeable. Lewy body deposits in the brain are associated with Lewy body dementia only. The degree of dementia progression often depends on underlying factors, although there is some evidence suggesting that early-onset Alzheimer patients progress more rapidly. Irreversible organ failure is not a hallmark characteristic; instead, pain, constipation, and behavioral changes are the most common symptoms.

Noisy, congested respirations (known as "terminal secretions") are very common during the dying process, and are also sometimes referred to as a “death rattle”. Typically, they do not cause discomfort for the patient, but can be very distressing to family members. Repositioning the patient by turning him on his side can be helpful to decrease the noise associated with this situation. Anticholinergics can also be administered, but typically, once the secretions start, anticholinergic effectiveness is limited.

End-stage renal disease (ESRD) is diagnosed when <10% of normal renal function exists, and is often a consequence of diabetes or hypertension. Alcohol misuse or comorbidities such as coronary artery disease, peripheral vascular disease, or malnutrition may be present, but are not causative factors. Treatment includes dialysis, but also kidney transplantation. African Americans, not Hispanic populations, are disproportionately affected by ESRD. Oliguria, not polyuria, is a symptom of ESRD.

Patients with emphysema may find some relief from dyspnea by leaning forward while sitting, and placing arms over a table (“tripod position”), due to the lengthened tension-state of the diaphragm in this position. Lowering the head of the bed would likely worsen dyspnea; pursed mouth-breathing, rather than deep nose-breathing, would be of greater benefit to lessening dyspnea; although guided imagery may improve mood, evidence does not demonstrate that it affects dyspnea directly.

John's symptoms are due to right sided (diastolic) heart failure, when the ventricle does not fill adequately, leading to a generalized edema of the extremities and the hepatic system. Symptoms of right sided failure include nausea, anorexia, peripheral edema, ascites, weakness, and weight gain. Poor cardiac output, decreased ejection fraction, organ perfusion failure are indicative of left-sided heart failure.

Acute stroke is associated with aphasia (which may include difficulty with both understanding and with verbalizing speech), ataxia, numbness or paralysis of limbs or face, vision disturbances, and headaches, which may illicit vomiting. The other symptoms are not indicative of acute stroke symptoms.

Breakthrough pain is intermittent episodes of pain that occur in patients with chronic pain. This type of pain can be related to some type of activity, of unknown origin, or can occur as analgesic failure at the end of a pain medication's period of effectiveness. Opioid regimens for pain management in the hospice and palliative care setting should include a long-acting agent, once dosing need is established, and a short-acting agent to cover episodes of breakthrough pain.

Since the oral route is always preferred if possible, Madge should be converted to liquid dosing of her current long-acting pain medication q 4hrs ATC (convert from Oxycontin® to liquid oxycodone), while maintaining the same dosing as currently ordered for breakthrough pain. Since most liquid forms are quite concentrated, even patients who are minimally responsive can tolerate such small volumes in the buccal space and typically maintain excellent pain control.

A frequent misconception is that younger patients with few co-morbidities are at greatest risk for under-treatment for pain, but in fact the elderly, minorities, and women are most at risk for under-treatment. Of the four case scenarios, the 86-year old has two of the three risk factors.

Transdermal fentanyl, also known as a fentanyl patch, is a good choice for individuals with pain who cannot swallow or do not remember to take their medication, and would need to be titrated to effect for this patient. It is a particularly good choice for Margaret because she may be forgetful due to her brain metastasis, which would not improve by providing liquid morphine instead of tablets. As she does not live with a caregiver, depending on the neighbor to assure adequate pain management is not an effective plan. As Margaret is not in pain crisis, symptom control efforts should be initiated and the effect evaluated before referral to an inpatient hospice setting.

As constipation is a significant side effects of opioid therapy, any patient on an opioid should also be prescribed a prophylactic bowel regimen to prevent or manage constipation. Senna is a simulant laxative that chemically stimulates the bowel to increase motility. Ondansetron HCl is a 5-HT3 receptor antagonist, used to prevent nausea and vomiting; diphenhydramine is an antihistamine used to treat opioid- induced pruritus; pamidronate is a bisphosphonate used as an adjuvant to opioids for bone pain.

Jordan is experiencing end-of-dose failure, which indicates that in the last hours of the dosing cycle, the blood levels of the drug are decreasing before uptake of the next scheduled dose. This is different than breakthrough pain, characterized by episode of pain despite control of continuous baseline pain. By shortening the round-the-close drug interval, Jordan will experience more stable drug blood levels. Increasing the prn dosing would only result in a short-acting bolus just prior to the next dosing cycle and could cause sedation and other side effects. A switch to another opioid is not necessary as this is typically done due to an undesirable side effect. A corticosteroid would not provide the desired pain management result in the last hours of the dosing cycle.

Unexplained syncope, as well as previous cardiac arrest with resuscitation, and an embolic stroke originating from the cardiac system are all indicators of poor prognosis in this patient population.

Prioritizing energy use is an important aspect of supporting the hospice patient who is experiencing progressive weakness and fatigue. Helping the patient to identify which activities are most important to physical, emotional and spiritual needs empowers the patient to spend limited energy on those aspects that matter most to them.

To avoid vasovagal symptoms (tachycardia, hypotension, fainting), it is important to draw the fluid off slowly with no more than 1-1.5 liters removed at any one time. Fully draining the pleural space (if more than 1.5 liters is present) could result in pain, vasovagal responses, and cough. In the palliative setting, it is ideal to have a caregiver instructed on how to properly access the catheter. Drainage should never occur over an 8-hour period, as prolonged catheter access can result in infection or embolus.

Insertion of a nasogastric tube for decompression venting and emptying of stomach contents is the most appropriate intervention at this stage of obstruction. Bowel rest is necessary, but bowel rest alone will not empty the stomach contents and hopefully reduce vomiting. A Foley catheter will not improve the obstruction; introduction of food while the obstruction is present will only complicate the situation.

Michelle is experiencing hyperactive delirium, commonly seen at end of life just prior to non-responsiveness. Dimming the lights will reduce sensory stimulation and may calm Michelle. Haloperidol is commonly administered for this symptom and is typically effective. Transferring Michelle immediately would likely exacerbate her symptoms; although morphine would cause sedation, it is not the most appropriate drug for these symptoms. Confining Michelle is inappropriate; discontinuing any current medications would only exacerbate symptoms. A sitter is an appropriate intervention as Michelle may be at risk for falls, but raising the head of the bed is ineffective for these symptoms.

The Hospice Medicare and Medicaid Benefit pays for outpatient services such as emergency room visits when arranged by the hospice team. The benefit does not cover room and board for hospice services in a private home or room and board in a nursing home; it does not cover prescription drugs or treatment intended to cure the terminal illness. The benefit also requires that all care for the terminal illness  is given by the hospice provider chosen, with the exception of the patient's regular doctor or nurse practitioner, chosen to be the attending physician for the hospice care.

Medicare hospice regulations require that the hospice must provide bereavement services to the family and any other individuals that are identified on the bereavement care plan for up to 1 year following the patient's death. There is no distinction between direct family members and other individuals associated with the patient.

Patients may use allegory or metaphors to describe end of life experiences, to include descriptions of visions or discussions with others, and preparatory statements such as getting ready for a trip, packing, meeting old friends and family, or standing in line preparing to go somewhere. Denying Heidi's beliefs would likely upset her without positive effect; although it is possible that Heidi has delirium, her behavior/statement does not warrant increasing her pain medication; likewise, ignoring her statements would likely upset Heidi.

Using terms such as "I wish" and "I had hoped" acknowledge the changes that are obvious while respecting the family's spiritual wishes to not discuss death directly. Confronting the wife by accusing her of not being helpful or not being ready to talk about death devalues their beliefs about death; diverting the discussion to the medical director may be helpful, but is not the most appropriate choice.

Asking her to show you how she performs the skill is the most effective means of demonstrating competency. After instructing patients/caregivers regarding any given skill or task, the following should occur, as a minimum: (1) Request a statement of understanding; (2) Watch a return demonstration if appropriate; and (3) Document the response. These are essential aspects of ensuring adult learning and patient safety.

The hospice social worker would the most appropriate member of the IDT to help a patient and family who are struggling financially. Hospice social workers hold a unique knowledge of community resources and expertise for accessing them.

Changes at end of life may distress family members, to include loss of direct communication with the patient. It is important to educate families that the patient's behavior will then be the best indicator of pain and may include behaviors such as restlessness, muscle rigidity, grimacing, guarding, crying, moaning, irritability, diaphoresis, passivity, or aggression. A patient who has experienced pain up to the point of being non-verbal is unlikely to stop having pain, and the nurse should assume that pain management must remain a priority; likewise, there is no reason to assume that pain will escalate, so ongoing assessment is necessary. Initiating terminal sedation simply for becoming non-verbal is inappropriate.

The IDT includes patients and families as members to maintain the patient/family centered focus; all treatment plans are developed with the patient and family. The medical director is not the only leader in IDTs; decision-making is accomplished through coordination among all team members. CMS requires hospice IDTs to include a volunteer, not palliative IDTs. When professional disciplines operate independently, they function as a multidisciplinary team, but are not interdisciplinary, functioning interdependently and often with overlapping roles.

According to the Medicare Conditions of Participations for Hospices, a registered nurse must make a visit to the patient's home no less frequently than every 14 days for the purpose of supervising the care of the hospice aide. The hospice aide does not need to be present during the visit, unless an area of concern has been discovered.

The best option for involving the patient and family in the IDT discussion in the hospice house setting would be to hold the meeting at the patient's bedside. This would allow all parties to participate within the privacy of the patient's room.

Point of service documentation is documentation performed  during the patient care visit and is the best practice regarding use of the electronic health record in patient care. Since hospice and palliative care is provided in an interdisciplinary manner, several professionals may be accessing the same record to review collaborative notes within the same day. Delayed documentation creates a barrier to optimal patient care by making vital information inaccessible to other care providers. There are many benefits to point of service documentation, including increased accuracy in the patient care record, and decreased staff burn-out. When documentation is completed during the patient care visit, instead of after hours, hospice staff can enjoy personal time for self-care, instead of patient care.

HIPAA regulations protect patient privacy in all settings, so it would not be appropriate to share any information regarding your patient's condition. In addition to the protection that this affords your patient, this also lets others know that if they or a loved one ever needs hospice care, their information will also remain confidential.

In general, withholding or withdrawing therapy, also known as allowing natural death, can be ethically justified and can be determined by the patient's legal surrogate or the patient themselves. The interdisciplinary team alone does not have the authority to initiate withholding or withdrawing therapy; an ethics committee meeting may be helpful to define the situation, but is not required.