SOLE Chapter 05: Comfort and Sedation TEST BANK

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.

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 that 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.

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.

ANS: A

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 ventilator

rate will not help in this situation. 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 the airway is clear. There is no need to suction again.

DIF: Cognitive Level: Analyze/Analysis REF: p. 55

OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: C

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.

DIF: Cognitive Level: Apply/Application REF: p. 70 | Table 5-11

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: C

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 in patients

with varying levels of sedation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 60

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: D

Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties.

Patients who receive NMBs must also receive sedatives and pain medication.

DIF: Cognitive Level: Remember/Knowledge REF: p. 72

OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: B

A train-of-four response of two twitches (out of four) 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.

DIF: Cognitive Level: Remember/Knowledge REF: p. 73

OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: D

The priority in caring for agitated patients is safety. The least restrictive methods of keeping

the patient safe are appropriate. If possible, the tube or device causing irritation should be

removed, but if that is not possible, the nurse must prevent the patient from pulling it out.

Restraints are associated with an increased incidence of agitation and delirium. Therefore,

restraints should not be used unless as a last resort for combative patients. The least amount of

sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor

adding propofol is indicated and would be likely to prolong mechanical ventilation.

DIF: Cognitive Level: Apply/Application REF: p. 61

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce

anxiety. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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.

ANS: C

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

They do not have anticonvulsant properties.

DIF: Cognitive Level: Remember/Knowledge REF: p. 72

OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: A

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.

DIF: Cognitive Level: Apply/Application REF: p. 72

OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: D

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.

DIF: Cognitive Level: Remember/Knowledge REF: p. 59 | Table 5-5

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A

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. This

platelet count is elevated. 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 such as shown here.

DIF: Cognitive Level: Analyze/Analysis REF: p. 71

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce

anxiety. TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: C

The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to

assessment of facial grimacing.

DIF: Cognitive Level: Understand/Comprehension REF: p. 58 | Table 5-3

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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?"

ANS: B

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, what provides

relief, and duration.

DIF: Cognitive Level: Understand/Comprehension REF: p. 56

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: B

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.

DIF: Cognitive Level: Apply/Application REF: p. 59 | Table 5-4

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: C

From this list, the 86-year-old postoperative nursing home resident is at greatest risk due to

advanced age, cognitive impairment, and some degree of respiratory failure. The 96-year-old

has been provided eyeglasses and a hearing aid, which will decrease the risk of delirium.

Smoking is a possible risk for delirium. The 36-year-old is receiving medications as part of an

alcohol withdrawal protocol, which should decrease the risk for delirium.

DIF: Cognitive Level: Analyze/Analysis REF: p. 61 | Table 5-8

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: C

The greatest priority in managing delirium is to keep the patient safe. Sedation may contribute

to the development of delirium. Comfort and nutrition are important, but they are not

priorities.

DIF: Cognitive Level: Understand/Comprehension REF: p. 61

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce

anxiety, and prevent delirium. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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.

ANS: A

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 other activities, however;

if unit protocol does not allow the patient's own dog, the nurse should investigate the use of

therapy animals or the other options.

DIF: Cognitive Level: Apply/Application REF: p. 64

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce

anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Psychological Integrity

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

ANS: C

The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA

as this patient should be awake, cognitively intact, and will have the acute pain related to the

surgical procedure. 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.

DIF: Cognitive Level: Analyze/Analysis REF: p. 71 | Box 5-6

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce

anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: D

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.

DIF: Cognitive Level: Apply/Application REF: p. 72

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce

anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

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."

ANS: D

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.

DIF: Cognitive Level: Understand/Comprehension REF: p. 74

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce

anxiety, and prevent delirium. TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: C, D, E

Guided imagery is a powerful technique for controlling pain and anxiety, especially that

associated with painful procedures. Similar to guided imagery, a music therapy program

offers patients a diversionary technique for pain and anxiety relief. Likewise animal therapy

has many benefits for the critically ill patient. Anaerobic exercise is not a nonpharmacological

approach for managing pain and anxiety. Most critically ill patients are not able to participate

in art therapy.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 62-64

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce

anxiety. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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 patient.

ANS: A, C, D

Pain is defined by each patient, anxiety is associated with marked apprehension, and pain and

anxiety are often interrelated. Critically ill patients commonly have both pain and anxiety.

Anxiety does increase both morbidity and mortality in critically ill patients, especially those

with cardiovascular disease.

DIF: Cognitive Level: Understand/Comprehension REF: p. 53

OBJ: Define pain and anxiety. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A, B, C, D, E

All of these factors predispose the patient to pain or anxiety.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 53-54

OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A, B, D, E

Both pain and anxiety are subjective in nature. One can exacerbate the other in a vicious cycle

that often requires good nursing assessment to manage the precipitating problem and break the

cycle. Anxiety is a response to a real or perceived fear. Pain is a response to real or "phantom"

phenomenon but always involves transmission of nerve impulses. Both relate to the patient's

perceptions of pain and fear. Previous experiences of both pain and/or anxiety can influence

the patient's perception of both. Anxiety is a response to real or perceived fear, and pain is a

response to a real or "phantom" phenomenon.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54

OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: A, B, D, E

Unlike pain, anxiety is linked to the reward and punishment centers in the limbic system of

the brain. It is totally neurological and does not involve tissue injury. Like pain, it is a

subjective phenomenon. Noise, light, and other stimuli can increase the intensity of anxiety.

Both anxiety and pain are subjective in nature.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-55

OBJ: Discuss the physiology of pain and anxiety.

TOP: Nursing Process Step: Assessment

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.

ANS: A, B, C, D, E

Anxiety is likely to result from loss of control, the inability to communicate, continuous noise

and lighting, excessive stimulation (including repeated vital sign measurements), lack of

mobility, and uncomfortable room temperatures. Increased anxiety levels often lead to

increased pain perception. Environments that are perceived as hostile also contribute.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54

OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: A, C, D

In the healthy person, pain and anxiety are adaptive mechanisms used to increase performance

levels or to remove one from potential harm. The "fight or flight" response occurs in response

to pain and/or anxiety and involves the activation of the sympathetic nervous system. Pain and

anxiety, however, can induce significant stress. The SNS is activated, not limited, by pain

and/or anxiety.

DIF: Cognitive Level: Remember/Knowledge REF: p. 55

OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A, D

The PQRST method and the Pain Intensity Scale require verbalization and/or writing to

communicate pain level. The FACES scale and the Visual Analogue Scale can be used by

simply having the patient point to the appropriate place. Because of this, they are the easiest to

use with children, people with language barriers, and intubated patients. The CAM tool is

used to assess delirium.

DIF: Cognitive Level: Apply/Application REF: pp. 57-58

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A, B, D

Delirium appears in approximately 80% of patients in the intensive care unit. Delirium is

characterized by changing mental status, inattention, disorganized thinking, and altered levels

of consciousness. Patients in the intensive care unit may not be able to verbalize because of

the presence of an artificial airway, sedative medication, neuromuscular blocking agents, or

brain injury. Effective nurse-to-patient communication and assessment skills would facilitate

assessment of pain and anxiety. There are tools and assessment methods to assess pain in

ventilated patients.

DIF: Cognitive Level: Understand/Comprehension REF: p. 56

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A, B, C, D, E

Manipulating the environment so that it appears less hostile helps decrease anxiety, as does

continually reorienting the patient. Focus techniques such as guided imagery and music

therapy can create a state of relaxation. Personal items can reduce anxiety and provide a

pleasant distraction.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 61-64

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce

anxiety. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: A, B, D

PCA is safe and effective, provides good-quality analgesia, and has potentially fewer side

effects than other routes. PCA management is rarely appropriate for critically ill patients

because most patients are unable to depress the button, or they are too ill to manage their pain

effectively. If the patient is cognitively intact, family assistance is not needed to use this

modality and is not advisable; the patient needs to be able to push the button.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 69-70

OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce

anxiety. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

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.

ANS: A, C, D

Pancuronium is a neuromuscular blocking agent (NMB) resulting in complete paralysis of the

patient. Patients receiving NMB must be provided total care, including eye, skin, and oral care

interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced

paralysis and bed rest. Sedatives must be administered concurrently with NMB, because

NMBs have no sedative effects. Although many critically ill patients are assisted to the chair,

chair activity is not appropriate for patients receiving NMB; passive exercise is most

appropriate. Feeding the patient on an NMB orally is not possible.

DIF: Cognitive Level: Analyze/Analysis REF: p. 73

OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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

ANS: A, C, D, E

All except for apathy are characteristics of hyperactive delirium. Apathy is seen in hypoactive

cases.

DIF: Cognitive Level: Understand/Comprehension REF: p. 59 | Table 5-4

OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity