Question 1

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

Accepted Answer

The best approach for administering benzodiazepines (and all sedatives)is to administer and titrate to a desired endpoint using a standard sedation scale.Administering around the clock as well as giving the highest allowable dose without basing it on an assessment target may result in excessive sedation.For greatest effect,most benzodiazepines are given intravenously.

Question 2

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

Accepted Answer

A train-of-four response of two twitches using a peripheral nerve stimulator indicates adequate paralysis.The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness.The Bispectral Index provides an assessment of sedation.The CAM-ICU is a tool to assess delirium.

Question 3

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

Accepted Answer

Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment.The Richmond Agitation Sedation Scale is a commonly used tool that has been validated.The CAM-ICU assesses for delirium.The FACES scale assesses pain.The Glasgow Coma Scale assesses neurological status.

Question 4

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?

Accepted Answer

Ibuprofen can result in renal insufficiency,which may be noted in an elevated serum creatinine level.Thrombocytopenia (low platelet count)is another possible side effect.An elevated white blood count indicates infection.Although ibuprofen is cleared primarily by the kidneys,it is also important to assess liver function,which would show elevated liver enzymes,not low values.

Question 5

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

Accepted Answer

Neuromuscular blocking (NMB)agents do not possess any sedative or analgesic properties.Patients who receive NMBs must also receive a sedative agent.

Question 6

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.

Accepted Answer

The Behavioral Pain Scale issues the most points,indicating the greatest amount of pain,to assessment of facial grimacing.

Question 7

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:

Accepted Answer

When patients exhibit signs of anxiety or agitation,the first priority is to identify and treat the underlying cause,which could be hypoxemia,hypoglycemia,hypotension,pain,or withdrawal from alcohol and drugs.Treatment is not initiated until assessment is completed.Medication may not be needed if the underlying cause can be resolved.

Question 8

Nociceptors differ from other nerve receptors in the body in that they:

Accepted Answer

Nociceptors are stimulated by mechanical,chemical,or thermal stimuli.Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response.The body continues to experience pain until the stimulus is discontinued or therapy is initiated.This is a protective mechanism so the body tissues being damaged will be removed from harm.Nociceptors usually initiate inflammatory responses near injured capillaries.As such,the response promotes infiltration of injured tissues with neutrophils and eosinophils.

Question 9

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?

Accepted Answer

If the patient can describe the pain,the nurse can assess quality,such as sharp,dull,or crushing.The other responses relate to continuous or intermittent presence (A),what provides relief (C),and duration (D).

Question 10

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

Accepted Answer

The greatest priority in managing delirium is keeping the patient safe.Sedation may contribute to development of delirium.Comfort and nutrition are important,but they are not priorities.

Question 11

The most important nursing intervention for patients who receive neuromuscular blocking agents is to:

Accepted Answer

Neuromuscular blocking agents cause paralysis only; they do not cause sedation.Therefore,concomitant administration of sedatives is essential.Neurological status is monitored according to unit protocol.Nurses should communicate with all critically ill patients,regardless of their status.If the patient is paralyzed,restraining devices may not be needed.

Question 12

The nurse is caring for four patients on the progressive care unit.Which patient is at greatest risk for developing delirium?

Accepted Answer

From this list,the elderly,postoperative,nursing home resident is at greatest risk.The 96-year-old has been provided eyeglasses and a hearing aid,which will decrease the risk of delirium.Renal failure is a risk for delirium,but an elevated BUN does not always indicate renal failure.The 36-year-old is receiving medications as part of an alcohol withdrawal protocol,which should decrease the risk for delirium.

Question 13

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

Accepted Answer

The patient undergoing bariatric surgery (an elective procedure)is the best candidate for PCA.The quadriplegic would be unable to operate the PCA pump.The cardiac surgery patient with mild dementia may not understand how to operate the pump.Likewise,the patient with the closed head injury may not be cognitively intact.

Question 14

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

Accepted Answer

Nonpharmacological approaches are helpful in reducing stress and anxiety,and each of these activities has the potential for improving the patient's well-being.The patient is likely to benefit most from the presence of his or her own dog rather than the therapy dog.

Question 15

A 45-year-old male postsurgical patient is on a ventilator in the critical care unit.He has been tolerating the ventilator well and has not required any sedation.He becomes tachycardic and hypertensive.His respiratory rate has increased to 28 breaths/min.The ventilator is set on synchronized intermittent mandatory ventilation (SIMV)at a rate of 10 breaths/min.The patient has been suctioned recently via his endotracheal tube,and his airway is clear.He responds appropriately to the nurse's commands.The nurse should:

Accepted Answer

Pulse,respirations,and blood pressure frequently result from activation of the sympathetic nervous system by the pain stimulus.Because the patient is postoperative,the patient should be assessed for the presence of pain and need for pain medication.Decreasing the SIMV does nothing because the patient is already overriding the ventilator.Providing sedation may calm the patient but will not solve the problem if the physiological changes are from pain.The patient has just been suctioned and his lungs are clear.There is no need to suction again.

Question 16

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?

Accepted Answer

Fighting the ventilator is rated with the greatest number of points for compliance with the ventilator,and could indicate pain or anxiety.Absence of vocal sounds (e.g.,no crying)and relaxed muscles do not indicate pain and are not given a point value.The patient may be moving the legs as a method of range of motion,not necessarily in response to pain.The patient needs to be assessed for restlessness if the movement is excessive.

Question 17

Neuromuscular blocking agents are used in the management of some ventilated patients.Their primary mode of action is:

Accepted Answer

These agents cause respiratory muscle paralysis.They do not provide analgesia or sedation.They do not have anticonvulsant properties.

Question 18

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:

Accepted Answer

The BIS and PSI have very simple steps for application,and results are displayed as raw EEG data and the numeric value.A single electrode is placed across the patient's forehead and is attached to a monitor.These monitors can be used in both children and adults,and patients with varying levels of sedation.

Question 19

The nurse is concerned about the risk of alcohol withdrawal syndrome in a 45-year- old postoperative patient.Which statement indicates her understanding of management of this patient?

Accepted Answer

The most important treatment of alcohol withdrawal syndrome is prevention.Many units have protocols that are initiated early to prevent the syndrome.Alcohol withdrawal syndrome is common; however,this statement does not indicate knowledge of management.The patient experiencing alcohol withdrawal may exhibit a variety of symptoms,such as disorientation,agitation,and tachycardia.Patients with substance abuse require increased dosages of pain medications.

Question 20

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:

Accepted Answer

Restraints are associated with an increased incidence of agitation and delirium.Therefore,the least restrictive methods of restraint are recommended,which is the soft wrist restraints.The Posey-type vest will not prevent self-extubation.The least amount of sedation is also recommended; therefore,neither increasing the dosage of lorazepam nor adding propofol is indicated and would likely prolong mechanical ventilation.

Quiz 5: Comfort and Sedation