ACHPN certification for palliative care NPs and CNSs

A patient with metastatic lung cancer has been declining for 2 weeks. Which new finding MOST specifically indicates that death is likely within 3 days?

Mark a letter. The key, plus a line on every option, opens at once.

1. respiration with mandibular movement

   Breathing with jaw movement belongs to the late cluster of signs, with loss of the radial pulse and very low urine output, that is highly specific for death within about three days.
2. sleeping most of the day and night

   Sleeping most of the day often starts weeks before death, so it shows decline without narrowing the timing to days.
3. new episodes of urinary incontinence

   New incontinence follows weakness and has many causes; it is common in decline and is not a specific marker of the last days.
4. decreased food and fluid intake

   Falling food and fluid intake is an early, near-universal change of the final weeks, which makes it a poor predictor of death within days.

A patient with ALS has troublesome drooling and has become confused on a scopolamine patch. Which medication reduces saliva with the LEAST central nervous system effect?

1. Amitriptyline

   Amitriptyline does reduce saliva, but as a tertiary tricyclic it enters the brain and adds sedation and delirium risk in a patient who is already confused.
2. Trihexyphenidyl

   Trihexyphenidyl is a centrally acting anticholinergic; it does dry saliva, but it readily causes the same confusion the scopolamine did.
3. Glycopyrrolate

   Glycopyrrolate is a quaternary anticholinergic that barely crosses the blood-brain barrier, so it dries saliva without adding to the confusion the scopolamine caused.
4. Diphenhydramine

   The anticholinergic drying of diphenhydramine comes with strong central sedation and delirium risk, the very effect to avoid here.

A patient with metastatic ovarian cancer and a prognosis of weeks has germline BRCA testing pending. Which topic is MOST important for the APRN to discuss now?

1. Canceling the pending germline test right away

   Canceling the pending germline test throws away information that may guide relatives' screening and prevention.
2. Waiting to talk about it until the results come back

   Waiting until the results come back risks the patient dying before choosing who should receive them.
3. Ordering tumor testing to confirm the variant

   Ordering tumor testing does not confirm an inherited variant and leaves open what happens to the germline result after death.
4. Naming who receives the results if death comes first

   Germline results matter to relatives, so naming who receives the results if death comes first lets the information reach family as the patient wishes.

A patient with metastatic lung cancer is admitted with pneumonia. The patient's goal is to return home, and it is uncertain whether IV antibiotics will restore the previous level of function. The APRN's BEST recommendation is

1. withholding antibiotics now.

   Withholding antibiotics now presumes the outcome and ignores a goal that treatment might still serve.
2. a time-limited trial with agreed endpoints.

   A time-limited trial gives antibiotics a fair chance to serve the goal of going home, with endpoints and a review date set in advance so the plan changes if function does not return.
3. full treatment until the fever resolves.

   Treating until the fever breaks sets a physiologic target with no link to the goal of returning home with acceptable function.
4. delaying treatment for family consensus.

   Waiting for family consensus postpones care even though the patient has already stated the goal.