NUR 425 Exam #1 CC UPDATED ACTUAL
Exam Questions and CORRECT Answers
what type of pain assessments do they use in the ICU for non-verbal patients - CORRECT
ANSWER - CPOT and BPS
t/f you treat pain after you treat sedation? - CORRECT ANSWER - False; treat pain first
always
what is the purpose of sedation? - CORRECT ANSWER - -reduces complications
-aids patient comfort
what is the typical goal for sedation (RASS)? - CORRECT ANSWER - +1 to -1
why do we want a patient to be under light sedation? - CORRECT ANSWER - want them
to be relaxed but easily arousable
t/f nurses can titrate sedation drips? - CORRECT ANSWER - true; need an order but once
order is in place they can titrate
what are some ways that a nurse can combat delirium? - CORRECT ANSWER - keep
patient on a normal cycle (turn on lights during the day and avoid going into their room
frequently at night)
t/f a sedated patient gets REM sleep because they are sedated - CORRECT ANSWER -
false; patients do not get good REM sleep when sedated
what percentage of ICU patients have delirium? - CORRECT ANSWER - 50%
,what assessment is used for delirium? - CORRECT ANSWER - Confusion assessment
method ICU (CAM-ICU)
who is at risk for delirium? - CORRECT ANSWER - 1) older patients
2) dementia, stroke, HIV, other CNS injury
3) complex surgery
4) drug withdrawal pt
5) trauma pt
What is the ABCDEF bundle? (nursing care for delirium) - CORRECT ANSWER -
Awakening
Breathing
Coordination
Delirium monitoring
Early mobility
Family engagement and empowerment
t/f sleep disruption and immobility contribute to ICU delerium? - CORRECT ANSWER -
true
how can we decrease a pt risk of delirium with immobility? - CORRECT ANSWER -
encourage them to participate in PT, turn and reposition patient
how can we decrease a pt risk of delirium with sleep disruption? - CORRECT ANSWER -
noise reduction, cluster care
t/f propofol increases sleep quality - CORRECT ANSWER - false; it reduces quality sleep
, what is the drug class for baclofen? - CORRECT ANSWER - centrally acting muscle
relaxant
why would you give someone baclofen? - CORRECT ANSWER - - spinal chord injury
- MS
- cerebral palsy
- hyperactive reflexes
what are the main ADR for baclofen? - CORRECT ANSWER - CNS depression
t/f you should not stop baclofen abruptly? - CORRECT ANSWER - true; could have
withdrawal symptoms
what is the drug class for dantrolene? - CORRECT ANSWER - peripherally acting muscle
relaxant
why would you give someone dantrolene? - CORRECT ANSWER - - relieves muscle
spasms
- CVA/stroke
- spinal chord injury
- malignant hyperthermia
what are the main ADR for dantrolene? (3 D's) - CORRECT ANSWER - Drowsiness
Dizziness
Diarrhea
t/f someone with liver disease can take dantrolene? - CORRECT ANSWER - false;
dantrolene is liver toxic
Exam Questions and CORRECT Answers
what type of pain assessments do they use in the ICU for non-verbal patients - CORRECT
ANSWER - CPOT and BPS
t/f you treat pain after you treat sedation? - CORRECT ANSWER - False; treat pain first
always
what is the purpose of sedation? - CORRECT ANSWER - -reduces complications
-aids patient comfort
what is the typical goal for sedation (RASS)? - CORRECT ANSWER - +1 to -1
why do we want a patient to be under light sedation? - CORRECT ANSWER - want them
to be relaxed but easily arousable
t/f nurses can titrate sedation drips? - CORRECT ANSWER - true; need an order but once
order is in place they can titrate
what are some ways that a nurse can combat delirium? - CORRECT ANSWER - keep
patient on a normal cycle (turn on lights during the day and avoid going into their room
frequently at night)
t/f a sedated patient gets REM sleep because they are sedated - CORRECT ANSWER -
false; patients do not get good REM sleep when sedated
what percentage of ICU patients have delirium? - CORRECT ANSWER - 50%
,what assessment is used for delirium? - CORRECT ANSWER - Confusion assessment
method ICU (CAM-ICU)
who is at risk for delirium? - CORRECT ANSWER - 1) older patients
2) dementia, stroke, HIV, other CNS injury
3) complex surgery
4) drug withdrawal pt
5) trauma pt
What is the ABCDEF bundle? (nursing care for delirium) - CORRECT ANSWER -
Awakening
Breathing
Coordination
Delirium monitoring
Early mobility
Family engagement and empowerment
t/f sleep disruption and immobility contribute to ICU delerium? - CORRECT ANSWER -
true
how can we decrease a pt risk of delirium with immobility? - CORRECT ANSWER -
encourage them to participate in PT, turn and reposition patient
how can we decrease a pt risk of delirium with sleep disruption? - CORRECT ANSWER -
noise reduction, cluster care
t/f propofol increases sleep quality - CORRECT ANSWER - false; it reduces quality sleep
, what is the drug class for baclofen? - CORRECT ANSWER - centrally acting muscle
relaxant
why would you give someone baclofen? - CORRECT ANSWER - - spinal chord injury
- MS
- cerebral palsy
- hyperactive reflexes
what are the main ADR for baclofen? - CORRECT ANSWER - CNS depression
t/f you should not stop baclofen abruptly? - CORRECT ANSWER - true; could have
withdrawal symptoms
what is the drug class for dantrolene? - CORRECT ANSWER - peripherally acting muscle
relaxant
why would you give someone dantrolene? - CORRECT ANSWER - - relieves muscle
spasms
- CVA/stroke
- spinal chord injury
- malignant hyperthermia
what are the main ADR for dantrolene? (3 D's) - CORRECT ANSWER - Drowsiness
Dizziness
Diarrhea
t/f someone with liver disease can take dantrolene? - CORRECT ANSWER - false;
dantrolene is liver toxic
