Comfort/sedation (chapter 6)

Question 1

Nociceptors differ from other nerve receptors in the body in that they:
A. adapt very little to continual pain response.
B. inhibit the infiltration of neutrophils and eosinophils.
C. play no role in the inflammatory response.
D. transmit only the thermal stimuli.

Answer 1

A. adapt very little to continual pain response.

Question 2

A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse’s commands. The nurse should:

a. assess the patient’s level of pain.
b. decrease the ventilator rate.
c. provide sedation as ordered.
d. suction the patient again.

Answer 2

a. assess the patient’s level of pain.

Question 3

The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse’s first priority is to

a. administer antianxiety medications as ordered.
b. administer pain medication as ordered.
c. identify and treat the underlying cause.
d. reassess the patient hourly to determine whether symptoms resolve on their own.

Answer 3

c. identify and treat the underlying cause.

Question 4

Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they

a. can be used only on heavily sedated patients.
b. can be used only on pediatric patients.
c. provide raw EEG data and a numeric value.
d. require only five leads.

Answer 4

c. provide raw EEG data and a numeric value.

Question 5

The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with nontraditional modes. The nurse understands that neuromuscular blocking agents provide:

a. antianxiety effects.
b. complete analgesia.
c. high levels of sedation.
d. no sedation or analgesia.

Answer 5

d. no sedation or analgesia.

Question 6

The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?

a. Glasgow Coma Scale score of 3
b. Train-of-four yields two twitches
c. Bispectral index of 60
d. CAM-ICU positive

Answer 6

b. Train-of-four yields two twitches

Question 7

The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for

a. arm binders or splints.
b. a higher dosage of lorazepam.
c. propofol.
d. soft wrist restraints.

Answer 7

d. soft wrist restraints.

Question 8

The primary mode of action for neuromuscular blocking agents used in the management of some ventilated patients is

a. analgesia.
b. anticonvulsant therapy.
c. paralysis.
d. sedation.

Answer 8

c. paralysis.

Question 9

The most important nursing intervention for patients who receive neuromuscular blocking agents is to
A. administer sedatives in conjunction with the neuromuscular blocking agents. B. assess neurological status every 30 minutes.
C. avoid interaction with the patient, because he or she won’t be able to hear.
D. restrain the patient to avoid self-extubation.

Answer 9

administer sedatives in conjunction with the neuromuscular blocking agents.

Question 10

The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the:

a. Confusion Assessment Method (CAM-ICU).
b. FACES assessment tool.
c. Glasgow Coma Scale.
d. Richmond Agitation Sedation Scale.

Answer 10

d. Richmond Agitation Sedation Scale.

Question 11

The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen?

a. Creatinine: 3.1 mg/dL
b. Platelet count 350,000 billion/L
c. White blood count 13, 550 mm3
d. ALT 25 U/L

Answer 11

a. Creatinine: 3.1 mg/dL

Question 12

The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes as indicating the greatest level of pain.

a. brow lowering
b. eyelid closing
c. grimacing
d. relaxed facial expression

Answer 12

c. grimacing

Question 13

The nurse wishes to assess the quality of a patient’s pain. Which of the following questions is appropriate to obtain this assessment if the patient is able to give a verbal response?

a. “Is the pain constant or intermittent?”
b. “Is the pain sharp, dull, or crushing?”
c. “What makes the pain better? Worse?”
d. “When did the pain start?”

Answer 13

b. “Is the pain sharp, dull, or crushing?”

Question 14

The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool. Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?

a. Absence of vocal sounds
b. Fighting the ventilator
c. Moving legs in bed
d. Relaxed muscles in upper extremities

Answer 14

b. Fighting the ventilator

Question 15

The nurse is caring for four patients on the progressive care unit. Which patient is at greatest risk for developing delirium?
a. 36-year-old recovering from a motor vehicle crash; being treated with an evidence-based alcohol withdrawal protocol.
b. 54-year-old postoperative aortic aneurysm resection with a 40 pack-year history of smoking
c. 86-year-old from nursing home with dementia, postoperative from colon resection, still being
mechanically ventilated
d. 95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid

Answer 15

c. 86-year-old from nursing home with dementia, postoperative from colon resection, still being
mechanically ventilated

Question 16

The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions toward keeping the patient:

a. comfortable.
b. nourished.
c. safe.
d. sedated.

Answer 16

c. safe.

Question 17

The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended period. Which of the following nursing interventions would improve the patient’s well-being and reduce anxiety the most?

a. Arrange for the patient’s dog to be brought into the unit (per protocol).
b. Provide aromatherapy with scents such as lavender that are known to help anxiety.
c. Secure the harpist to come and play soothing music for an hour every afternoon.
d. Wheel the patient out near the unit aquarium to observe the tropical fish.

Answer 17

a. Arrange for the patient’s dog to be brought into the unit (per protocol).

Question 18

The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia (PCA)?

a. Patient with a C4 fracture and quadriplegia
b. Patient with a femur fracture and closed head injury
c. Postoperative patient who had elective bariatric surgery
d. Postoperative cardiac surgery patient with mild dementia

Answer 18

c. Postoperative patient who had elective bariatric surgery

Question 19

The nurse is caring for a patient receiving a benzodiazepine intermittently. The nurse understands that the best way to administer such drugs is to:

a. administer around the clock, rather than as needed, to ensure constant sedation.
b. administer the medications through the feeding tube to prevent complications.
c. give the highest allowable dose for the greatest effect.
d. titrate to a predefined endpoint using a standard sedation scale.

Answer 19

d. titrate to a predefined endpoint using a standard sedation scale.

Question 20

The nurse is concerned about the risk of alcohol withdrawal syndrome in a postoperative patient. Which statement by the nurse indicates understanding of management of this patient?

a. “Alcohol withdrawal is common; we see it all of the time in the trauma unit.”
b. “There is no way to assess for alcohol withdrawal.”
c. “This patient will require less pain medication.”
d. “We have initiated the alcohol withdrawal protocol.”

Answer 20

d. “We have initiated the alcohol withdrawal protocol.”

Question 21

Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of critically ill patients include: (Select all that apply.)

a. anaerobic exercise.
b. art therapy.
c. guided imagery.
d. music therapy.
e. animal therapy.

Answer 21

c. guided imagery.
d. music therapy.
e. animal therapy.

Question 22

Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
a. Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal.
b. Critically ill patients often experience anxiety, but they rarely experience pain.
c. Pain and anxiety are often interrelated and may be difficult to differentiate because their
physiological and behavioral manifestations are similar.
d. Pain is defined by each patient; it is whatever the person experiencing the pain says it is.
e. While anxiety is unpleasant, it does not contribute to mortality or morbidity of the critically ill

Answer 22

a. Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal.
c. Pain and anxiety are often interrelated and may be difficult to differentiate because their
physiological and behavioral manifestations are similar.
d. Pain is defined by each patient; it is whatever the person experiencing the pain says it is.

Question 23

Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that apply.)

a. Inability to communicate
b. Invasive procedures
c. Monitoring devices
d. Nursing care
e. Preexisting conditions

Answer 23

a. Inability to communicate
b. Invasive procedures
c. Monitoring devices
d. Nursing care
e. Preexisting conditions

Question 24

Choose the items that are common to both pain and anxiety. (Select all that apply.)

a. Cyclical exacerbation of one another
b. Require good nursing assessment for proper treatment
c. Response only to real phenomena
d. Subjective in nature
e. Perception may be influenced by prior experience

Answer 24

a. Cyclical exacerbation of one another
b. Require good nursing assessment for proper treatment
d. Subjective in nature
e. Perception may be influenced by prior experience

Question 25

Anxiety differs from pain in that: (Select all that apply.)

a. it is confined to neurological processes in the brain.
b. it is linked to reward and punishment centers in the limbic system.
c. it is subjective.
d. there is no actual tissue injury.
e. it can be increased by noise and light.

Answer 25

a. it is confined to neurological processes in the brain.
b. it is linked to reward and punishment centers in the limbic system.
d. there is no actual tissue injury.
e. it can be increased by noise and light.

Question 26

Factors in the critical care unit that may predispose the client to increased pain and anxiety include: (Select all that apply.)

a. an endotracheal tube.
b. frequent vital signs.
c. monitor alarms.
d. room temperature.
e. hostile environment.

Answer 26

a. an endotracheal tube.
b. frequent vital signs.
c. monitor alarms.
d. room temperature.
e. hostile environment.

Question 27

In the healthy individual, pain and anxiety: (Select all that apply.)

a. activate the sympathetic nervous system (SNS).
b. decrease stress levels.
c. help remove one from harm.
d. increase performance levels.
e. limit sympathetic nervous system activity.

Answer 27

a. activate the sympathetic nervous system (SNS).
c. help remove one from harm.
d. increase performance levels.

Question 28

The nurse is caring for a patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is responsive, the nurse is not able to read the patient’s lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use when assessing the patient’s pain level? (Select all that apply.)

a. The FACES scale
b. Pain Intensity Scale
c. The PQRST method
d. The Visual Analogue Scale
e. The CAM tool

Answer 28

a. The FACES scale

d. The Visual Analogue Scale

Question 29

In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.)

a. Administration of neuromuscular blocking agents
b. Delirium
c. Effective nurse communication and assessment skills
d. Nonverbal patients
e. Ventilated patient

Answer 29

a. Administration of neuromuscular blocking agents
b. Delirium
d. Nonverbal patients

Question 30

Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.)

a. Environmental manipulation
b. Explanations of monitoring equipment
c. Guided imagery
d. Music therapy
e. Provision of personal items

Answer 30

a. Environmental manipulation
b. Explanations of monitoring equipment
c. Guided imagery
d. Music therapy
e. Provision of personal items

Question 31

The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered patient-
controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.)
a. is a safe and effective method for administering analgesia.
b. has potentially fewer side effects than other routes of analgesic administration.
c. is an ideal method to provide most critically ill patients some control over their treatment.
d. provides good quality analgesia.
e. does not work well without family assistance.

Answer 31

a. is a safe and effective method for administering analgesia.
b. has potentially fewer side effects than other routes of analgesic administration.
d. provides good quality analgesia.

Question 32

A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The
nursing care for this patient includes: (Select all that apply.)
a. administration of sedatives concurrently with neuromuscular blockade.
b. dangling the patient’s feet over the edge of the bed and assisting the patient to sit up in a chair at
least twice each day.
c. ensuring that deep vein thrombosis prophylaxis is initiated.
d. providing interventions for eye care, oral care, and skin care.
e. ensuring good nutrition with frequent feedings throughout the day.

Answer 32

a. administration of sedatives concurrently with neuromuscular blockade.
c. ensuring that deep vein thrombosis prophylaxis is initiated.
d. providing interventions for eye care, oral care, and skin care.

Question 33

The nurse is assessing the critically ill patient for delirium. The nurse recognizes which characteristics that
indicate hyperactive delirium? (Select all that apply.)
a. Agitation
b. Apathy
c. Biting
d. Hitting
e. Restlessness

Answer 33

a. Agitation
c. Biting
d. Hitting
e. Restlessness