Chapter 09: Sedation, Agitation, and Delirium Management

Urden: Critical Care Nursing, 8th Edition

MULTIPLE CHOICE

1. To achieve ventilator synchrony in a mechanically ventilated patient with acute respiratory

distress syndrome (ARDS), which level of sedation might be most effective?
a. Light
b. Moderate
c. Conscious
d. Deep
ANS: D
Deep sedation is used when the patient must be unresponsive to deliver necessary care safely.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 138|Box 9-1

OBJ: Nursing Process Step: Planning
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

2. A patient has been taking benzodiazepines and suddenly develops respiratory depression and
hypotension. After careful assessment, the nurse determines that the patient is experiencing
benzodiazepine overdose. What is the nurse’s next action?
a. Decrease benzodiazepines to half the prescribed dose.
b. Increase IV fluids to 500 cc/h for 2 hours.
c. Administer flumazenil (Romazicon).
d. Discontinue benzodiazepine and start propofol.
ANS: C
The major unwanted side effects associated with benzodiazepines are dose-related respiratory
depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to reverse
benzodiazepine overdose in symptomatic patients.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 138|Box 9-1

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

3. A patient is admitted unit with acute respiratory distress syndrome (ARDS). The patient has
been intubated and is mechanically ventilated. The patient is becoming increasingly agitated,
and the high-pressure alarm on the ventilator has been frequently triggered. What action
should be the nurse take first?
a. Administer midazolam 5 mg by intravenous push immediately.
b. Assess the patient to see if a physiologic reason exists for his agitation.
c. Obtain an arterial blood gas level to ensure the patient is not hypoxemic.
d. Apply soft wrist restraints to keep him from pulling out the endotracheal tube.
ANS: B
The first step in determining the need for sedation is to assess the patient quickly for any
physiologic causes that can be quickly reversed. In this case, endotracheal suctioning may
solve the high-pressure alarm problem.
 PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 141
OBJ: Nursing Process Step: Intervention
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

4. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been
intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and
the high-pressure alarm on the ventilator has been frequently triggered. The patient continues
to be very agitated, and the nurse can find nothing physiologic to account for the high-
pressure alarm. What action should the nurse take next?
a. Administer midazolam 5 mg by intravenous push immediately.
b. Eliminate noise and other stimuli in the room and speak softly and reassuringly to
the patient.
c. Obtain an arterial blood gas to ensure the patient is not becoming more
hypoxemic.
d. Call the respiratory care practitioner to replace the malfunctioning ventilator.
ANS: B
Optimizing the environment, speaking calmly, explaining things to the patient, and providing
distractions are all nonpharmacologic means to decrease anxiety.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 144

OBJ: Nursing Process Step: Intervention
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

5. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been
intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and
the high-pressure alarm on the ventilator has been frequently triggered. Despite the nurse’s
actions, the patient continues to be agitated, triggering the high-pressure alarm on the
ventilator. Which medication would be appropriate to sedate the patient this time?
a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the
patient is no longer triggering the alarm
b. Haloperidol 5 mg IVP stat
c. Propofol 5 mcg/kg/min by IV infusion
d. Fentanyl 25 mcg IVP over a 15-minute period
ANS: A
Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be
used for short- and intermediate-term sedation. Haloperidol is indicated for dementia.
Fentanyl is a narcotic and is not appropriate for use as a sedative.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 144

OBJ: Nursing Process Step: Intervention
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

6. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been
intubated and is mechanically ventilated. The patient had become very agitated and required
some sedation. After the patient’s agitation is controlled, which medications would be most
appropriate for long-term sedation?
 a. Morphine 2 mg/h continuous IV drip
b. Haloperidol 15 mcg/kg/min continuous IV infusion
c. Propofol 5 mcg/kg/min by IV infusion
d. Lorazepam 0.01 to 0.1 mg/kg/h by IV infusion
ANS: D
Propofol may be used for ongoing sedation for short- and intermediate-term sedation (1–3
days) and should be coupled with a short-acting opioid analgesic. Morphine is an opioid
analgesic and is not sedation. Lorazepam infusion (0.01–0.1 mg/kg/h) is recommended for
long-term sedation.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 144|Table 9-2

OBJ: Nursing Process Step: Intervention
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

7. When administering propofol over an extended period, what laboratory value should the nurse
routinely monitor?
a. Serum triglyceride level
b. Sodium and potassium levels
c. Platelet count
d. Acid–base balance
ANS: A
Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid
content.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 144|Table 9-2

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

8. What is a major side effect of benzodiazepines?

a. Hypertension
b. Respiratory depression
c. Renal failure
d. Phlebitis
ANS: B
The major side effects of benzodiazepines include hypotension and respiratory depression.
These side effects are dose related.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 141|Table 9-2

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

9. What is the major advantage of using propofol as opposed to another sedative for short-term
sedation?
a. Fewer side effects
b. Slower to cross the blood–brain barrier
c. Shorter half-life and rapid elimination rate
 d. Better amnesiac properties
ANS: C
Propofol is an effective short-term anesthetic agent, useful for rapid “wake-up” of patients for
assessment; if continuous infusion is used for many days, emergence from sedation can take
hours or days; sedative effect depends on the dose administered, depth of sedation, and length
of time sedated.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 144|Box 9-2

OBJ: Nursing Process Step: Evaluation
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

10. Which of the following medications is used for sedation in patients experiencing withdrawal
syndrome?
a. Dexmedetomidine
b. Hydromorphone
c. Diazepam
d. Clonidine
ANS: D
Clonidine (often prescribed as a Catapres patch) is a central a-agonist and is recommended for
sedation during withdrawal syndrome.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 140

OBJ: Nursing Process Step: Intervention
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

11. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The
patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the
bedding. The nurse suspects the patient may be experiencing what issue?
a. Delirium
b. Hypoxemia
c. Hypocalcemia
d. Sedation withdrawal
ANS: A
Delirium is represented by a global impairment of cognitive processes, usually of sudden
onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions
(hallucinations), abnormal thought processes, and inappropriate behavior. There is no
evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going
through sedation withdrawal.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 141

OBJ: Nursing Process Step: Diagnosis
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

12. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The
patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the
bedding. What is the medication of choice for treating this patient?
 a. Diazepam
b. Haloperidol
c. Lorazepam
d. Propofol
ANS: B
Haloperidol is the drug of choice when treating delirium. Lorazepam has been associated with
an increased incidence of delirium. Propofol is indicated for sedation use. Diazepam is not an
appropriate choice for this patient.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 141

OBJ: Nursing Process Step: Planning
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

13. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The
patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the
bedding. What parameter should be monitored while the patient is haloperidol?
a. Sedation level
b. QTc-interval
c. Oxygen saturation level
d. Brain waves
ANS: B
Electrocardiogram (ECG) monitoring is recommended because haloperidol use can produce
dose-dependent QTc-interval prolongation, with an increased incidence of ventricular
dysrhythmias. BIS monitoring is indicated for deep sedation use.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 141

OBJ: Nursing Process Step: Implementation
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Pharmacological Therapies| NCLEX: Safety and Infection Control

14. What is the most common contributing factor to the development of delirium in critically ill
patients?
a. Sensory overload
b. Hypoxemia
c. Electrolyte disturbances
d. Sleep deprivation
ANS: D
Delirium is frequently associated with critical illness. Provision of adequate sleep and early
mobilization are recommended to reduce the incidence of delirium.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 141

OBJ: Nursing Process Step: Diagnosis
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

15. Which medication has a greater advantage for treatment of alcohol withdrawal syndrome
(AWS) because of its longer half-life and high lipid solubility?
a. Lorazepam
 b. Midazolam
c. Propofol
d. Diazepam
ANS: D
Management of alcohol withdrawal involves close monitoring of AWS-related agitation and
administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam (Ativan).
Diazepam has the advantage of a longer half-life and high lipid solubility. Lipid-soluble
medications quickly cross the blood–brain barrier and enter the central nervous system to
rapidly produce a sedative effect. Midazolam is the recommended drug for use in alleviating
acute agitation but is known to cause seizures with AWS because of rapid withdrawal.
Propofol is indicated for sedation use.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 144|Table 9-2

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

16. What are the risk factors for delirium?

a. Hypertension, alcohol abuse, and benzodiazepine administration
b. Coma, hypoxemia, and trauma
c. Dementia, hypertension, and pneumonia
d. Coma, alcohol abuse, hyperglycemia
ANS: A
Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of
illness, coma, and benzodiazepine administration.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 141|p. 145|Figure 9-1

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

17. What are the two scales that are recommended for assessment of agitation and sedation in
adult critically ill patients?
a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS)
b. Ramsay Scale and Motor Activity Assessment Scale (MAAS)
c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale
(RASS)
d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale
(MAAS)
ANS: C
The two scales that are recommended for assessment of agitation and sedation in adult
critically ill patients are the SAS and the RASS.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 137

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

18. Which intervention is an effective nursing strategy to decrease the incidence of delirium?
 a. Restriction of visitors
b. Early nutritional support
c. Clustering of nursing care activities
d. Bedrest
ANS: C
As lack of sleep is a major contributor to the development of delirium, interventions to
promote sleep should help decrease the incidence of delirium. Some critical care units have
initiated sleep protocols to increase the opportunity for patients to sleep at night, dimming
lights at night, ensuring there are periods of time when tubes are not manipulated, and
clustering nursing care interventions to provide some uninterrupted rest periods. Early
ambulation is also appropriate.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 144

OBJ: Nursing Process Step: Intervention
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE

1. What are the causes of delirium in critically ill patients? (Select all that apply.)
a. Hyperglycemia
b. Meningitis
c. Cardiomegaly
d. Pulmonary embolism
e. Alcohol withdrawal syndrome
f. Hyperthyroidism
ANS: B, E, F
The causes of delirium in critically ill patients include metabolic causes (acid–base
disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural
hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor),
endocrine causes (hyperthyroidism or hypothyroidism, Addison disease, hyperparathyroidism,
Cushing syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic
shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes (alcohol
withdrawal syndrome, benzodiazepines, heavy metal poisoning).

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 144-145|Box 9-2

OBJ: Nursing Process Step: Assessment
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity

2. Which complications can result from prolonged deep sedation? (Select all that apply.)
a. Pressure ulcers
b. Thromboembolism
c. Diarrhea
d. Nosocomial pneumonia
e. Delayed weaning from mechanical ventilation
f. Hypertension
ANS: A, B, D, E
Oversedation can result in a multitude of complications. Prolonged deep sedation is associated
with significant complications of immobility, including pressure ulcers, thromboembolism,
gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 138

OBJ: Nursing Process Step: Diagnosis
TOP: Sedation, Agitation, and Delirium: Assessment and Management
MSC: NCLEX: Physiologic Integrity