CCRN Pain, Agitation, and Delirium Management

Question 1

Which validated tool is recommended by the Society of Critical Care Medicine (SCCM) for assessing pain in non-verbal ICU patients?

Accepted Answer

Behavioral Pain Scale (BPS)

Answer

Glasgow Coma Scale

Answer

Richmond Agitation-Sedation Scale

Answer

FLACC Scale

Question 2

A RASS score of -2 indicates which level of sedation?

Accepted Answer

Moderate sedation — movement or eye opening without eye contact

Answer

Alert and calm

Answer

Light sedation — briefly awakens to voice

Answer

Deep sedation — no response to voice

Question 3

The SCCM PADIS guidelines recommend which target RASS level for most mechanically ventilated ICU patients?

Accepted Answer

0 to -2

Answer

-4 to -5

Answer

-3 to -4

Answer

+1 to +2

Question 4

Which assessment tool is considered the gold standard for detecting ICU delirium in mechanically ventilated patients?

Accepted Answer

Confusion Assessment Method for the ICU (CAM-ICU)

Answer

Mini-Mental State Examination (MMSE)

Answer

Delirium Rating Scale

Answer

Montreal Cognitive Assessment (MoCA)

Question 5

Which non-pharmacological intervention is a first-line strategy to prevent and treat ICU delirium?

Accepted Answer

Early mobility and physical therapy

Answer

Haloperidol administration

Answer

Propofol infusion

Answer

Benzodiazepine taper

Question 6

A patient on a propofol infusion develops hypertriglyceridemia, metabolic acidosis, and cardiac dysfunction. Which condition should the nurse suspect?

Accepted Answer

Propofol infusion syndrome (PRIS)

Answer

Serotonin syndrome

Answer

Neuroleptic malignant syndrome

Answer

Malignant hyperthermia