C HAPTER 07: P AIN AND P AIN M ANAGEMENT
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. Why use a specific pain intensit y scale in the critical care unit?
a. It eliminates the subjective component from the assessment.
b. It focuses on the objective component of the assessment .
c. It provides consistency of assessment and management.
d. It provides a way to interpret physiologic indicators.
ANS: C
Many critical care units use a specific pain intensit y scale because a
single tool provides consistency of assessment, management, and
documentation. A pain intensit y scale is useful in the critical care
environment. Asking the patient to grade his or her pain on a scale of 0
to 10 is a consistent method and aids the nurse in objectifying the
subjective nature of the patient’s pain. Howeve r, the patient’s tool
preference should be considered.
PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing
Process Step: Assessment TOP: Pain and Pain Management
MSC: NC LEX: Physiological Integrit y: Reduction of Risk
Potential
,2. The patient is sedated and breathing with the use of mechanical
ventilation. The patient is unable to communicate any aspects of his pain
to the nurse. What tool should the nurse use to assess the patient’s pain?
a. FLACC
b. Wong-Baker FACES
c. BIS
d. BPS
ANS: D
The BPS and the CPOT are supported by experts in critical care and are
suggested for use in medical, postoperative, and nonbrain trauma
criticall y ill adults unable to self -report in the clinical guidelines of
the Societ y of Critical Care Medicine ( SCCM). FLACC is a pediatric
pain assessment tool. The Wong -Baker FACES tool requires the patient
to associate a level of pain to a facial representation. BIS is as an
objective measure of sedation levels during neuromuscular blockade in
the critical care unit.
PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing
Process Step: Assessment TOP: Pain and Pain Management
MSC: NC LEX: Physiological Integrit y: Reduction of Risk
Potential
3. Which patient is MOST likel y to be experiencing a life -threatening
opioid side effect?
a. Patient with respiratory rate of 10 breaths/min who is breathing
deepl y
b. Patient with a respiratory rate of 8 breaths/min who is difficult to
arouse
, c. Patient with blood pressure of 150/75 mm Hg and heart rate of
102 beats/min
d. Patient with a temperature of 100.5°F w ho is asleep but easil y
roused
ANS: B
Although no universal definition of respiratory depression exists, it is
usuall y described in terms of decreased respiratory rate (fewer than 8
or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels.
A change in the patient’s level of consciousness is a warning sign. It
can be a sign of respiratory depression associated with airway
obstruction by the tongue, leading to hypoxemia and possibl y to
cardiorespiratory arrest. A patient snoring after the adminis tration of
an opioid requires the critical care nurse to observe closel y.
PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing
Process Step: Evaluation TOP: Pain and Pain Management
MSC: NC LEX: Physiological Integrit y: Reduction of Risk
Potential
4. The nurse is caring for a patient with moderate pain. What is the
maximum dose of acetaminophen the patient should receive in 24 hours?
a. 1 g
b. 2 g
c. 4 g
d. 500 mg
ANS: C
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. Why use a specific pain intensit y scale in the critical care unit?
a. It eliminates the subjective component from the assessment.
b. It focuses on the objective component of the assessment .
c. It provides consistency of assessment and management.
d. It provides a way to interpret physiologic indicators.
ANS: C
Many critical care units use a specific pain intensit y scale because a
single tool provides consistency of assessment, management, and
documentation. A pain intensit y scale is useful in the critical care
environment. Asking the patient to grade his or her pain on a scale of 0
to 10 is a consistent method and aids the nurse in objectifying the
subjective nature of the patient’s pain. Howeve r, the patient’s tool
preference should be considered.
PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing
Process Step: Assessment TOP: Pain and Pain Management
MSC: NC LEX: Physiological Integrit y: Reduction of Risk
Potential
,2. The patient is sedated and breathing with the use of mechanical
ventilation. The patient is unable to communicate any aspects of his pain
to the nurse. What tool should the nurse use to assess the patient’s pain?
a. FLACC
b. Wong-Baker FACES
c. BIS
d. BPS
ANS: D
The BPS and the CPOT are supported by experts in critical care and are
suggested for use in medical, postoperative, and nonbrain trauma
criticall y ill adults unable to self -report in the clinical guidelines of
the Societ y of Critical Care Medicine ( SCCM). FLACC is a pediatric
pain assessment tool. The Wong -Baker FACES tool requires the patient
to associate a level of pain to a facial representation. BIS is as an
objective measure of sedation levels during neuromuscular blockade in
the critical care unit.
PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing
Process Step: Assessment TOP: Pain and Pain Management
MSC: NC LEX: Physiological Integrit y: Reduction of Risk
Potential
3. Which patient is MOST likel y to be experiencing a life -threatening
opioid side effect?
a. Patient with respiratory rate of 10 breaths/min who is breathing
deepl y
b. Patient with a respiratory rate of 8 breaths/min who is difficult to
arouse
, c. Patient with blood pressure of 150/75 mm Hg and heart rate of
102 beats/min
d. Patient with a temperature of 100.5°F w ho is asleep but easil y
roused
ANS: B
Although no universal definition of respiratory depression exists, it is
usuall y described in terms of decreased respiratory rate (fewer than 8
or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels.
A change in the patient’s level of consciousness is a warning sign. It
can be a sign of respiratory depression associated with airway
obstruction by the tongue, leading to hypoxemia and possibl y to
cardiorespiratory arrest. A patient snoring after the adminis tration of
an opioid requires the critical care nurse to observe closel y.
PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing
Process Step: Evaluation TOP: Pain and Pain Management
MSC: NC LEX: Physiological Integrit y: Reduction of Risk
Potential
4. The nurse is caring for a patient with moderate pain. What is the
maximum dose of acetaminophen the patient should receive in 24 hours?
a. 1 g
b. 2 g
c. 4 g
d. 500 mg
ANS: C
