CCRN Pain, Agitation, and Delirium Management 1 — Questions and Answers
Question 1: Which validated tool is recommended by the Society of Critical Care Medicine (SCCM) for assessing pain in non-verbal ICU patients?
- Glasgow Coma Scale
- Behavioral Pain Scale (BPS) (Correct answer)
- Richmond Agitation-Sedation Scale
- FLACC Scale
Correct answer: Behavioral Pain Scale (BPS)
The Behavioral Pain Scale (BPS) is a validated tool for assessing pain in non-verbal, mechanically ventilated ICU patients.
Question 2: A RASS score of -2 indicates which level of sedation?
- Alert and calm
- Light sedation — briefly awakens to voice
- Moderate sedation — movement or eye opening without eye contact (Correct answer)
- Deep sedation — no response to voice
Correct answer: Moderate sedation — movement or eye opening without eye contact
A RASS of -2 indicates light sedation, where the patient briefly awakens (eye opening and contact) to voice for less than 10 seconds.
Question 3: The SCCM PADIS guidelines recommend which target RASS level for most mechanically ventilated ICU patients?
- -4 to -5
- -3 to -4
- 0 to -2 (Correct answer)
- +1 to +2
Correct answer: 0 to -2
PADIS guidelines recommend a target RASS of 0 to -2 (light sedation) to promote earlier liberation from mechanical ventilation and reduce delirium.
Question 4: Which assessment tool is considered the gold standard for detecting ICU delirium in mechanically ventilated patients?
- Mini-Mental State Examination (MMSE)
- Confusion Assessment Method for the ICU (CAM-ICU) (Correct answer)
- Delirium Rating Scale
- Montreal Cognitive Assessment (MoCA)
Correct answer: Confusion Assessment Method for the ICU (CAM-ICU)
The CAM-ICU is the gold-standard validated tool for diagnosing delirium in ICU patients, including those on mechanical ventilation.
Question 5: Which non-pharmacological intervention is a first-line strategy to prevent and treat ICU delirium?
- Haloperidol administration
- Early mobility and physical therapy (Correct answer)
- Propofol infusion
- Benzodiazepine taper
Correct answer: Early mobility and physical therapy
Early mobility and physical therapy are first-line non-pharmacological strategies proven to reduce the incidence and duration of ICU delirium.
Question 6: A patient on a propofol infusion develops hypertriglyceridemia, metabolic acidosis, and cardiac dysfunction. Which condition should the nurse suspect?
- Serotonin syndrome
- Neuroleptic malignant syndrome
- Propofol infusion syndrome (PRIS) (Correct answer)
- Malignant hyperthermia
Correct answer: Propofol infusion syndrome (PRIS)
Propofol infusion syndrome (PRIS) is a rare but life-threatening complication characterized by metabolic acidosis, hypertriglyceridemia, rhabdomyolysis, and cardiac failure.
CCRN Pain, Agitation, and Delirium Management 1
Which validated tool is recommended by the Society of Critical Care Medicine (SCCM) for assessing pain in non-verbal ICU patients?