CHPN study guide: the five HPCC domains and their traps

A hospice patient with advanced cirrhosis is being assessed during care planning. Which finding most strongly suggests developing hepatic encephalopathy?

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

1. Increasing abdominal girth with new ankle edema

   Growing girth and ankle swelling suggest ascites and fluid retention from portal hypertension and low albumin, not encephalopathy.
2. Difficulty concentrating and a reversed sleep cycle

   Subtle attention problems and sleeping by day while awake at night are among the earliest signs of hepatic encephalopathy, often noticed before frank confusion or asterixis.
3. Darker urine along with pale, clay-colored stools

   Dark urine with pale stools signals blocked bile flow, a liver finding but not a sign of encephalopathy.
4. Generalized itching with increasing daytime fatigue

   Itching reflects retained bile salts and fatigue is common in cirrhosis; neither points to the brain effects of ammonia and other toxins.

During the initial hospice assessment, a patient with amyotrophic lateral sclerosis (ALS) mentions morning headaches and now sleeps propped up on several pillows. Which area should the nurse give highest priority?

1. Respiratory muscle weakness and breathing status

   Morning headaches and needing to sleep propped up point to weak breathing muscles and poor ventilation at night, the problem that drives distress and most deaths in ALS, so it comes first.
2. Nutritional status and the presence of dysphagia

   Swallowing and nutrition matter in ALS, but these symptoms come from failing breathing muscles, which take priority.
3. Speech clarity and the ability to communicate needs

   Communication aids help with planning, but they do nothing for the breathing problem these symptoms reveal.
4. Extremity weakness and the resulting mobility limits

   Limb weakness shapes equipment and safety needs, but the headaches and the need to sleep upright signal a more urgent breathing problem.

A patient with end-stage renal disease stopped dialysis 6 days ago and is receiving hospice care. Which assessment finding most strongly suggests that death is imminent?

1. New swelling of both ankles and lower legs

   Edema follows fluid retention after dialysis ends and may appear early; it reflects volume status rather than how near death is.
2. Rising creatinine and BUN on the latest labs

   Climbing creatinine and BUN are expected as soon as dialysis stops, so they do not time the death, and hospice rarely draws them.
3. Worsening itching that disrupts sleep at night

   Uremic itch is distressing and worth treating, but it can persist for weeks and does not mark the final days.
4. Drowsiness progressing to unresponsiveness

   Once dialysis stops, uremic toxins build up and cause deepening somnolence that moves toward coma, usually in the last days of life.

A patient with advanced multiple sclerosis has painful spasticity with frequent leg spasms. Which adjuvant is most appropriate?

1. Methocarbamol

   Methocarbamol is used for short-term muscle spasm after strains and sprains, does not reduce spasticity from central nervous system disease, and is sedating.
2. Baclofen

   Baclofen acts on GABA-B receptors in the spinal cord to reduce spasticity of central origin, so it treats the spasms that drive this patient's pain.
3. Acetaminophen

   Acetaminophen eases mild pain in general but has no effect on the muscle tone that causes the spasms in MS.
4. Nortriptyline

   This tricyclic is an adjuvant for neuropathic pain such as burning dysesthesia in MS, not for spasticity and painful spasms.

A hospice patient has needed gradual opioid dose increases over several weeks. Which finding most suggests disease progression, rather than tolerance, as the cause of the rising dose needs?

1. Similar pain that needs slightly higher doses over time

   The same pain needing a little more drug over time is the textbook picture of tolerance, the very explanation the stem asks to set aside.
2. Stable relief after each small scheduled dose increase

   Relief that returns with each small increase fits slowly developing tolerance to the same pain; nothing new has appeared.
3. New pain at a different site with a changed quality

   Pain in a new place or with a new character means a new pain source, which points to the disease advancing rather than the body adapting to the drug.
4. Unchanged pain pattern with steady rescue-dose use

   A stable pattern with steady breakthrough use shows that control is holding; it gives no sign of a new lesion.

A 68-year-old patient with lung cancer and rib metastases has aching pain that worsens with movement despite scheduled opioids. Renal function is normal and there is no history of GI bleeding. Which adjuvant is most appropriate to add?

1. Gabapentin

   Gabapentin targets neuropathic pain, while aching rib pain that worsens with movement is mainly nociceptive bone pain.
2. Tramadol

   Tramadol is a weak opioid, not an adjuvant, and adds serotonergic and seizure risks on top of the scheduled opioids.
3. Lorazepam

   A benzodiazepine treats anxiety, not bone pain, and adds sedation and fall risk on top of scheduled opioids.
4. Naproxen

   Pain from bone metastases is driven partly by prostaglandins, so an NSAID adds relief that opioids alone often miss; normal kidneys and no bleeding history remove the usual barriers.

A hospice patient who is expected to die within days becomes restless and keeps pulling at the bed linens. Before giving an as-needed sedative, the nurse should first check for:

1. a low blood glucose by fingerstick testing

   Fingersticks in a patient dying within days add burden and seldom explain restlessness; a bedside check of bladder and bowel comes first.
2. urinary retention or fecal impaction

   A full bladder or impacted stool is a common, quickly fixed cause of terminal restlessness, and sedating the patient would leave that discomfort in place.
3. an oxygen saturation below 90 percent

   Low saturation is expected in the last days and checking it does not change comfort care; oxygen rarely settles restlessness at this stage.
4. a new infection needing antibiotics

   Searching for an infection to treat with antibiotics does not fit a patient expected to die within days and delays the simple bedside check.

A patient with advanced lung cancer has severe fatigue but still wants to "do more" during the day. Which care-plan goal is most appropriate?

1. Do all self-care each day without any help

   Full independence in self-care is unrealistic here, and spending energy on bathing and dressing can leave none for what the patient cares about.
2. Raise energy ratings from 3 to 8 within a week

   A jump that large in one week is not a realistic outcome of fatigue care in advanced disease, and it says nothing about what the patient wants to do.
3. Walk around the block daily to build endurance

   Building endurance is a rehabilitation aim; with severe fatigue in advanced cancer it sets the patient up to fail and uses up the day's energy.
4. Sit in a chair for 20 minutes while family visits

   Sitting up in a chair for a family visit is a short, specific goal tied to something the patient values, so limited energy goes where it matters most, the core of energy conservation.

A hospice patient with lung cancer eats the high-calorie meals the family provides but keeps losing weight and muscle mass. What is the primary driver of this weight loss?

1. Systemic inflammation and altered metabolism

   Systemic inflammation from tumor and immune signals, with altered metabolism, breaks down muscle and fat whatever the intake, which is why extra calories alone do not reverse cachexia.
2. Poor absorption of nutrients in the gut

   Malabsorption can cause weight loss, but nothing here such as diarrhea or fatty stools suggests it, and it does not explain muscle wasting despite eating.
3. Psychological aversion to the meals offered

   An aversion to food would show up as eating less, yet this patient is eating and still losing weight.
4. Inadequate calorie intake for daily needs

   The patient is eating high-calorie meals; blaming intake is the starvation model, which feeding would correct, and cachexia does not behave that way.

A hospice patient with moderate dementia who lives with an adult child has been taking extra doses of oxycodone. Which intervention is most appropriate?

1. Secure the opioid supply and have the caregiver give doses

   With memory impairment the patient cannot reliably track doses, so locking up the supply and moving administration to the caregiver removes the overdose risk.
2. Set out the day's doses in a pill organizer for the patient

   An organizer helps people who remember to use it correctly; a patient with moderate dementia can still empty the next compartments early.
3. Reduce the prescribed dose to offset the extra tablets

   Cutting the dose to make up for extra tablets needs a prescriber's order, still leaves the patient free to take more, and may leave pain undertreated.
4. Teach the patient to record each dose on a wall calendar

   A calendar depends on the same memory that is already failing, so the patient may still take extra tablets.

The spouse of a hospice patient who is now bedbound and eating very little says, "Once we get the right vitamins, they'll be back on their feet." What is the most appropriate initial response by the nurse?

1. "Vitamins will not help; your spouse is dying and will not recover."

   The statement is blunt and comes before the nurse learns what the spouse understands, which can shut down trust and the conversation.
2. "That's a good idea. Which vitamins would you like me to order?"

   Agreeing feeds the expectation that vitamins can reverse the decline, and the nurse cannot order supplements on request.
3. "Tell me what you have noticed about how they are doing this week."

   Asking what the spouse has noticed this week invites them to describe the decline in their own words, which opens the way to gentle teaching without stripping away hope.
4. "Talk to our counselor about accepting what is happening."

   Sending the spouse to a counselor as a first reply sidesteps the nurse's own role in exploring the hope and can feel dismissive.

During a home visit, the spouse of a dying patient begins crying and says, "I know they're dying, but I can't imagine life without them." What is the most supportive response by the nurse?

1. "It helps to stay positive and enjoy the time you still have together."

   Urging positivity glosses over the sadness the spouse just voiced; well meant, it shuts the feeling down instead of exploring it.
2. "Focus on keeping them comfortable now, and deal with your own feelings afterward."

   Telling the spouse to set feelings aside treats their grief as a distraction and adds to caregiver strain.
3. "It hurts to grieve someone who is still here. Tell me what that's like for you."

   Naming anticipatory grief and inviting the spouse to talk about it validates the pain now, while the patient is still alive.
4. "I'll ask the social worker to call you about this next month."

   Putting the conversation off to a later call leaves the spouse alone with grief that has already begun, when the nurse can respond now.

A hospice's QAPI data show that 30% of newly admitted patients do not have pain brought to a comfortable level within 48 hours. What is the QAPI program's next responsibility?

1. Analyzing causes and testing a measured fix

   QAPI exists to find out why care falls short and to test a change with data, so the next step is analyzing causes and then running a measured improvement project.
2. Identifying the admitting nurses for discipline

   Singling out the admitting nurses for discipline discourages reporting and ignores system causes; QAPI centers on processes, not blame.
3. Waiting for a survey to confirm the gap

   The hospice's own data already show the gap, and QAPI requires the hospice to act on its findings without outside confirmation.
4. Removing the pain measure from future reports

   Dropping a measure because results look bad hides the problem; poor performance is exactly what QAPI is meant to act on.

A hospice volunteer asks the volunteer coordinator whether they may give the patient's family a personal phone number so they can help after the patient dies. Which response is best?

1. Tell the volunteer to stop all contact with the family starting today

   Cutting off contact now, while the patient is alive and the volunteer is assigned, overcorrects and abandons the family.
2. Explain that support after death comes through the bereavement program

   Ongoing private contact blurs the volunteer's role; the hospice bereavement program is the structured, supervised way to support the family after the death.
3. Agree, since volunteers are not held to professional boundary standards

   Hospice volunteers are trained members of the team and follow the agency's boundary policies; being unpaid does not exempt them.
4. Agree if the volunteer limits contact to the first month after the death

   A time limit does not fix the boundary problem; private contact still falls outside the volunteer's defined role and the hospice's oversight.

Medicare pays hospices a daily (per diem) rate. Which factor primarily determines the rate that applies to a patient on a given day?

1. The specific medications the patient is taking

   Drugs related to the terminal illness are already covered inside the per diem, and the hospice gets no higher rate for costlier medications.
2. The patient's terminal diagnosis and its severity

   The hospice rate is not adjusted by diagnosis or severity the way hospital payments are; any terminal diagnosis gets the same rate for the same level of care.
3. The level of care the patient receives that day

   Medicare sets the hospice daily rate by the level of care provided that day: routine home care, continuous home care, inpatient respite care, or general inpatient care.
4. The patient's income and assets at admission

   Medicare hospice coverage does not depend on income or assets; means testing belongs to Medicaid eligibility, not to the daily rate.