1. A nurse receives a referral to evaluate a patient who has been receiving hospice services since 8 months ago. The patient will be entering which of the following benefit periods?
A. first
B. second
C. third Correct
D. fourth
Explanation
The Medicare Hospice Benefit consists of two initial 90-day periods (total 180 days) followed by unlimited 60-day periods. Eight months is roughly 240-245 days, which exceeds the 180-day mark by 60-65 days. Therefore, the patient has already completed the first two 90-day periods and is now entering the first 60-day period, which is the third benefit period overall. This structure allows continued eligibility as long as the terminal prognosis remains six months or less.
2. A patient has prostate cancer with bone metastasis and a history of seizures controlled with phenytoin. The oncologist orders dexamethasone for increased bone pain. Three weeks later, the patient has a seizure. The MOST likely cause of the seizure is
A. adverse reaction to dexamethasone
B. inhibition of phenytoin metabolism Correct
C. dexamethasone metabolites
D. metastasis to the brain
Explanation
Dexamethasone is a potent inducer of the CYP3A4 enzyme system, which significantly accelerates the hepatic metabolism of phenytoin. Over the three-week period, this induction lowers phenytoin blood levels, resulting in subtherapeutic concentrations and breakthrough seizures despite previously stable control. This drug-drug interaction is far more likely than new brain metastasis or direct steroid toxicity in this timeframe.
3. The epidural infusion rate of morphine and bupivacaine has recently been increased, and the patient now complains of decreased sensation in the lower extremities. Which of the following is the MOST likely cause of the decreased sensation?
A. morphine-bupivacaine interaction
B. epidural infection
C. too much bupivacaine Correct
D. too much morphine
Explanation
Bupivacaine is the local anesthetic component of epidural infusions and is solely responsible for sensory and motor blockade. Increasing the infusion rate delivers more bupivacaine to spinal nerve roots, producing the observed sensory loss in the lower extremities, whereas morphine at typical doses provides analgesia without significant sensory blockade.
4. While receiving palliative care, a patient's colostomy was revised secondary to obstruction. Now on hospice, the current colostomy is no longer viable, and an actively draining fistula has developed. The patient is comfortable. The family requests diagnostic tests to determine the tumor's size and location. Which of the following should be the nurse's FIRST response?
A. Explore the family's plans related to requested diagnostics Correct
B. Call the attending physician to report the new fistula
C. Assure the family the patient will remain comfortable
D. Recommend the patient return to palliative care
Explanation
In hospice, diagnostic testing is avoided unless it directly improves comfort. The nurse's first priority is to compassionately explore why the family wants imaging (curiosity, guilt, denial, or hope for reversal) so that underlying emotional or informational needs can be addressed rather than proceeding with non-beneficial tests that conflict with hospice goals.
5. The family of a patient with end-stage dementia has become dissatisfied with the care provided by the current hospice. After a care conference, the family decides to change to another hospice in the area. The current hospice should
A. ask the family to revoke the Medicare Hospice Benefit
B. arrange transfer of services Correct
C. discharge the patient for cause
D. revoke the Medicare Hospice Benefit
Explanation
Medicare regulations permit one hospice-to-hospice transfer per benefit period without requiring revocation of the overall hospice benefit. The current hospice must coordinate a smooth transfer and forward all records to the new agency.