Facts read from oncc.org · last checked Nov 7, 2026
Area IV asks how cancer and its treatment affect mood, coping, family and finances, and what an oncology NP screens for and refers to. Psychiatric diagnosis and drug choice in depth belong to the psychiatric NP pages; here the focus is the oncology-specific picture.
Practice questions
60 questions written to the AOCNP outline; each choice is explained once you pick.
NCCN's distress management guideline uses the Distress Thermometer, a 0–10 scale with a problem list, and sets 4 as the threshold for a closer look. The Commission on Cancer requires accredited programs to screen for distress. A high score is not a diagnosis: it leads to a clinical interview and, if depression or anxiety is suspected, a validated tool. Cut-off scores for those tools are on PMHNP-BC advanced practice skills.
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Tamoxifen and the antidepressant choice
Tamoxifen needs CYP2D6 to form its active metabolite, endoxifen. When a patient on tamoxifen needs an antidepressant, or a drug for hot flashes, strong CYP2D6 inhibitors such as paroxetine and fluoxetine are avoided; CPIC's 2018 tamoxifen guideline advises against them. Venlafaxine, a weak inhibitor, is a common alternative. This interaction is oncology's to know; general antidepressant selection is not.
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14 psychosocial scenarios
0 / 14 answered14 questions
Tap an option: why each one is right or wrong appears under it.
Psychosocial Issues · 10%
A 16-year-old with osteosarcoma refuses to return to school after an amputation and hair loss, saying classmates will stare. The APRN's best intervention is:
Homebound tutoring avoids the distress but deepens isolation and delays reintegration.
Peer acceptance and identity are central adolescent tasks, and AYA peer support reduces isolation and eases the return to school after visible changes from treatment.
Forcing attendance ignores the fear behind the refusal and can worsen avoidance.
Medication treats a depressive disorder, which has not been diagnosed; this is an adjustment and body-image concern.
On a FICA spiritual history, a patient with metastatic cancer says she feels abandoned by God and keeps asking 'why me?' She has no depressive symptoms. The APRN's next step is:
An anxiety group does not address an existential and religious struggle.
Spiritual distress without depressive symptoms is best addressed by a board-certified chaplain, the spiritual-care specialist of the team.
A psychiatric referral medicalizes spiritual distress in a patient who screens negative for depression.
Offering the APRN's own beliefs crosses professional boundaries and can impose a worldview.
A Navajo patient with lung cancer declines to discuss end-of-life planning because speaking of death could bring it about. The APRN's best approach is to:
Insisting on an advance directive overrides a cultural belief and can damage trust.
In traditional Navajo belief, speaking directly of death can bring it about; discussing choices hypothetically, as what some people in this situation decide, allows planning without violating that belief.
Waiting for him to raise it seems respectful but may leave his wishes unknown when decisions arise.
A culturally grounded refusal is not a sign of incapacity.
During the psychosocial evaluation before allogeneic stem cell transplant, the APRN must confirm that the patient has:
A history of depression is not a contraindication; it calls for support and monitoring.
Support group attendance is optional and not a prerequisite for transplant.
Continuous employment is not a requirement; many patients stop working during transplant.
Allogeneic transplant programs require a committed caregiver available around the clock for roughly the first 100 days, when complications can develop quickly at home.
Two months after a permanent colostomy for rectal cancer, a man avoids intimacy with his wife because he fears leakage and odor. The APRN:
Intimacy is safe with a stoma; saying otherwise is misinformation.
His avoidance stems from a practical fear, not a depressive disorder.
Advising abstinence reinforces the fear and is not needed medically.
A WOC nurse teaches practical measures for intimacy with a stoma (emptying the pouch beforehand, covers, positioning), and an ostomy peer visitor models adaptation.
A patient with newly diagnosed metastatic breast cancer says she "isn't thinking about the cancer right now," yet she keeps every appointment and follows her treatment plan. The APRN interprets this as:
Avoiding thoughts of cancer while functioning well is not a sign of PTSD or acute stress disorder.
Confronting protective denial can raise distress without improving care she is already accepting.
Denial that keeps a patient from being overwhelmed while she keeps every appointment is adaptive and is respected; it becomes a problem only when it interferes with care.
Choosing not to dwell on the illness does not mean she cannot understand or decide about treatment.
Per NCCN distress management guidelines, after screening at the initial visit, patients with cancer are rescreened for distress:
NCCN calls for distress screening at the initial visit and again at appropriate intervals and changes in disease status, such as recurrence, progression, or transitions in care.
Rescreening only patients who scored high misses those who become distressed later.
Relying on the patient to ask misses distress, which patients often under-report.
A single later screen misses distress during recurrence, progression, or end-of-life transitions.
A patient taking dexamethasone 16 mg/day for brain metastasis edema develops insomnia, irritability and pressured speech on day 4; neurologic symptoms have resolved and imaging is stable. The APRN first:
Steroid psychiatric effects are dose-related and often begin in the first week; with the edema controlled, tapering to the lowest effective dose is the first step.
A benzodiazepine treats a symptom, leaves the cause in place, and can worsen disinhibition or delirium.
Switching to an equivalent prednisone dose keeps the same glucocorticoid exposure that is causing the symptoms.
An SSRI takes weeks, does not target steroid-induced activation, and can worsen it.
During adjuvant chemotherapy, a patient reports 3 weeks of new word-finding and concentration problems; the neurologic examination is normal. The APRN's first step is to:
Cancer-related cognitive impairment is a diagnosis of exclusion, so the first step is to look for reversible contributors: mood, sleep, fatigue, anemia, thyroid or metabolic problems, and sedating or anticholinergic drugs.
Brain MRI is for focal findings or concern for metastases; the neurologic examination is normal.
Many patients improve after treatment ends, but reassurance without evaluation misses treatable causes.
Formal testing is reserved for progressive or disabling deficits after contributors are addressed.
A colon cancer survivor who completed FOLFOX reports forgetfulness and trouble multitasking at work. The MoCA is normal and depression screening is negative. The APRN recommends:
Ginkgo biloba did not improve cognition in a randomized trial in patients with cancer.
Donepezil has not shown consistent benefit in cancer survivors without dementia.
For cancer-related cognitive impairment with depression excluded, cognitive rehabilitation that teaches compensatory strategies, with physical activity, has the best supporting evidence.
Methylphenidate has not reliably improved cognition in survivors and is not a first-line approach.
Two years after treatment for stage II breast cancer, a woman with no evidence of disease checks her breasts several times a day, asks for scans before each visit, and avoids making plans. The APRN's best intervention is:
Repeated checking, reassurance-seeking, and avoidance after treatment point to clinically significant fear of cancer recurrence, which responds to targeted psychological interventions such as the ConquerFear program.
A scheduled benzodiazepine blunts anxiety for a while but does not change fear-driven checking, and it adds dependence risk.
Routine imaging is not recommended in follow-up of asymptomatic early breast cancer survivors, and reassurance from a scan fades quickly and feeds the checking.
Extra visits work as reassurance-seeking and tend to maintain the fear rather than reduce it.
A 45-year-old finishing pelvic external beam radiation and brachytherapy for cervical cancer asks how to protect her sexual function. The APRN recommends:
Waiting means treating established fibrosis, which is harder to reverse than to prevent.
Long abstinence does not protect the tissue and lets stenosis progress; intercourse or dilator use is encouraged once the acute reaction heals.
Pelvic radiation, especially with brachytherapy, causes vaginal fibrosis and stenosis; ASCO's sexual health guideline supports dilator use after treatment, with lubricants and moisturizers, to keep the vagina open for intercourse and pelvic examinations.
PDE-5 inhibitors have not shown benefit for female sexual dysfunction and do nothing for radiation-induced stenosis.
A running total sits here; it fills in after your last pick.
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Psycho-oncology distinctions that get tested
Demoralization or depression. Demoralization centers on hopelessness and loss of meaning, often with the capacity for pleasure in the moment intact; pervasive anhedonia points to depression.
Fear of recurrence. Some fear is expected after treatment. It becomes a clinical problem when it is persistent, excessive and interferes with function or follow-up.
Financial toxicity. Cost of care is a measurable outcome (the COST instrument) that changes adherence, so it is assessed, not assumed.
Benzodiazepines in older adults. Their risks in that age group are a Beers criteria topic, covered on FNP-C geriatrics.
Area IV lists assessment instruments, so know what the common tools measure. Cut-off scores and antidepressant selection are taught in depth on this site's PMHNP-BC pages.
How many AOCNP questions are psychosocial?
Area IV is 10% of the 125 scored questions, about 12 or 13 on a form.