MCQ Quiz: Management of Pain, Agitation, and Delirium in the Critically Ill Patient

The management of pain, agitation, and delirium (PAD) is a fundamental component of modern critical care practice and a core topic in the Acute Care curriculum. The current paradigm, often guided by the PADIS (Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption) guidelines, emphasizes an “analgesia-first” approach, targeted light sedation, and proactive delirium management to improve patient outcomes. As a critical care pharmacist, you must be proficient in using assessment tools like the CPOT and RASS, selecting appropriate pharmacotherapy, and implementing non-pharmacologic strategies. This quiz will test your knowledge on the integrated management of PAD in the ICU.

1. The current, evidence-based approach to managing pain and agitation in the ICU is known as:

• a) Deep sedation for all patients
• b) “Analgesia-first” sedation, where pain is treated before initiating sedatives
• c) Benzodiazepine-first sedation
• d) Sedation without any pain assessment Answer: b) “Analgesia-first” sedation, where pain is treated before initiating sedatives

2. A mechanically ventilated patient is unable to self-report pain. Which of the following is a validated and recommended tool for pain assessment in this patient?

• a) Richmond Agitation-Sedation Scale (RASS)
• b) Confusion Assessment Method for the ICU (CAM-ICU)
• c) A 0-10 Numeric Rating Scale (NRS)
• d) Critical-Care Pain Observation Tool (CPOT) Answer: d) Critical-Care Pain Observation Tool (CPOT)

3. What is the first-line pharmacologic therapy for treating non-neuropathic pain in critically ill patients?

• a) IV Acetaminophen
• b) IV Opioids (e.g., fentanyl, hydromorphone)
• c) IV Ketorolac
• d) IV Benzodiazepines Answer: b) IV Opioids (e.g., fentanyl, hydromorphone)

4. The Richmond Agitation-Sedation Scale (RASS) is used to assess a patient’s level of sedation. A RASS score of 0 indicates the patient is:

• a) Combative
• b) Deeply sedated
• c) Alert and calm
• d) Drowsy, but awakens to voice Answer: c) Alert and calm

5. Which sedative agent is preferred for light sedation in the ICU because it allows for a more “cooperative” and easily arousable state without causing significant respiratory depression?

• a) Lorazepam
• b) Midazolam
• c) Dexmedetomidine
• d) Haloperidol Answer: c) Dexmedetomidine

6. The primary tool for assessing delirium in an ICU patient is the:

• a) RASS scale
• b) Behavioral Pain Scale (BPS)
• c) Confusion Assessment Method for the ICU (CAM-ICU)
• d) Glasgow Coma Scale (GCS) Answer: c) Confusion Assessment Method for the ICU (CAM-ICU)

7. A major advantage of propofol for sedation is its:

• a) Long half-life, allowing for stable sedation.
• b) Lack of effect on blood pressure.
• c) Rapid onset and offset, allowing for quick awakenings for neurologic exams.
• d) Ability to be administered through a peripheral IV for weeks. Answer: c) Rapid onset and offset, allowing for quick awakenings for neurologic exams.

8. Propofol-related infusion syndrome (PRIS) is a rare but fatal complication associated with high doses and prolonged use. It is characterized by metabolic acidosis, rhabdomyolysis, and:

• a) Hypertension
• b) Acute cardiovascular collapse
• c) Hyperglycemia
• d) Respiratory alkalosis Answer: b) Acute cardiovascular collapse

9. The use of benzodiazepines (e.g., lorazepam, midazolam) for sedation in the ICU is an independent risk factor for the development of what complication?

• a) Acute kidney injury
• b) Delirium
• c) Hypertriglyceridemia
• d) Stress ulcers Answer: b) Delirium

10. What is the most effective strategy for the prevention and management of delirium in critically ill patients?

• a) Prophylactic administration of haloperidol.
• b) Deep sedation to keep the patient calm.
• c) A multicomponent, non-pharmacologic approach like the ABCDEF bundle.
• d) Continuous infusion of a benzodiazepine. Answer: c) A multicomponent, non-pharmacologic approach like the ABCDEF bundle.

11. The “A” and “B” in the ABCDEF bundle stand for:

• a) Analgesia and Benzodiazepines
• b) Awakening and Breathing Coordination
• c) Antibiotics and Blood cultures
• d) Atropine and Bicarbonate Answer: b) Awakening and Breathing Coordination

12. Dexmedetomidine’s mechanism of action is as a(n):

• a) GABA-A receptor agonist
• b) NMDA receptor antagonist
• c) Central alpha-2 adrenergic agonist
• d) Mu-opioid receptor agonist Answer: c) Central alpha-2 adrenergic agonist

13. A common dose-limiting side effect of dexmedetomidine is:

• a) Tachycardia and hypertension
• b) Bradycardia and hypotension
• c) Respiratory depression
• d) Seizures Answer: b) Bradycardia and hypotension

14. A Spontaneous Awakening Trial (SAT), or “sedation vacation,” involves:

• a) Increasing the sedative dose daily.
• b) Holding sedative infusions daily to assess the patient’s neurologic status and need for continued sedation.
• c) Switching from propofol to a benzodiazepine.
• d) Administering a reversal agent for the sedative. Answer: b) Holding sedative infusions daily to assess the patient’s neurologic status and need for continued sedation.

15. What is the primary role of antipsychotics like haloperidol or quetiapine in managing delirium?

• a) To treat the underlying cause of delirium.
• b) For delirium prevention in all ICU patients.
• c) To treat distressing symptoms like agitation or psychosis in delirious patients.
• d) To shorten the duration of delirium. Answer: c) To treat distressing symptoms like agitation or psychosis in delirious patients.

16. Which IV opioid has the fastest onset and shortest duration of action, making it suitable for managing acute, brief procedural pain?

• a) Morphine
• b) Hydromorphone
• c) Fentanyl
• d) Methadone Answer: c) Fentanyl

17. A pharmacist is consulted for a patient receiving high doses of lorazepam via continuous infusion. The pharmacist should be concerned about toxicity from which diluent?

• a) Dextrose 5%
• b) Propylene glycol
• c) Normal saline
• d) Sterile water Answer: b) Propylene glycol

18. The “E” and “F” in the ABCDEF bundle stand for:

• a) Electrolytes and Fluids
• b) Early Mobility and Family Engagement
• c) Epinephrine and Furosemide
• d) Echocardiogram and Follow-up Answer: b) Early Mobility and Family Engagement

19. When managing agitation in the ICU, benzodiazepines are now considered second-line to other sedatives but may be first-line for patients with:

• a) Sepsis
• b) Acute respiratory distress syndrome (ARDS)
• c) Alcohol or benzodiazepine withdrawal
• d) Heart failure Answer: c) Alcohol or benzodiazepine withdrawal

20. A patient’s RASS target is -1. This means the desired level of sedation is:

• a) Deeply sedated, no response to voice or physical stimulation.
• b) Alert and calm.
• c) Drowsy, but awakens to voice for >10 seconds.
• d) Anxious and agitated. Answer: c) Drowsy, but awakens to voice for >10 seconds.

21. “Analgesia-based sedation” or “analgosedation” refers to a strategy that:

• a) Uses a sedative first, followed by an analgesic.
• b) Uses an opioid analgesic as the primary agent to achieve both pain control and light sedation.
• c) Avoids all analgesics.
• d) Uses only non-opioid pain relievers for sedation. Answer: b) Uses an opioid analgesic as the primary agent to achieve both pain control and light sedation.

22. Which of the following is a significant risk factor for developing delirium in the ICU?

• a) Young age
• b) Pre-existing hypertension or dementia
• c) Use of dexmedetomidine
• d) Daily family visits Answer: b) Pre-existing hypertension or dementia

23. Propofol infusions can cause hypertriglyceridemia. It is important to monitor triglyceride levels, especially after how many days of therapy?

• a) 1 day
• b) 2 days
• c) 7 days
• d) 30 days Answer: b) 2 days

24. The CAM-ICU assessment for delirium first requires the assessment of:

• a) The patient’s pain level.
• b) The patient’s level of sedation using the RASS scale.
• c) The patient’s electrolyte levels.
• d) The patient’s ability to follow commands. Answer: b) The patient’s level of sedation using the RASS scale.

25. A multimodal analgesia strategy in the ICU might involve combining an IV opioid with which other agent to reduce opioid requirements?

• a) A benzodiazepine
• b) IV acetaminophen or ketamine
• c) Haloperidol
• d) Propofol Answer: b) IV acetaminophen or ketamine

26. Which opioid is known for causing histamine release, which can lead to hypotension and pruritus?

• a) Fentanyl
• b) Hydromorphone
• c) Morphine
• d) Remifentanil Answer: c) Morphine

27. Hypoactive delirium is characterized by:

• a) Agitation, restlessness, and emotional lability.
• b) Calmness and alertness.
• c) Lethargy, inattention, and reduced motor activity.
• d) A normal sleep-wake cycle. Answer: c) Lethargy, inattention, and reduced motor activity.

28. The pharmacist’s role in PAD management includes:

• a) Helping to select the most appropriate agent based on patient factors.
• b) Recommending appropriate starting doses and titrations.
• c) Monitoring for side effects and drug interactions.
• d) All of the above. Answer: d) All of the above.

29. The concept of linking a Spontaneous Awakening Trial (SAT) with a Spontaneous Breathing Trial (SBT) is designed to:

• a) Increase the duration of mechanical ventilation.
• b) Facilitate liberation from mechanical ventilation.
• c) Assess the patient’s pain level.
• d) Prevent delirium. Answer: b) Facilitate liberation from mechanical ventilation.

30. Which of the following is a non-pharmacologic method for managing pain in the ICU?

• a) Administering a high dose of fentanyl.
• b) Using music therapy or relaxation techniques.
• c) Keeping the patient in a noisy, brightly lit room.
• d) Using physical restraints. Answer: b) Using music therapy or relaxation techniques.

31. The accumulation of midazolam’s active metabolites is a significant concern in patients with:

• a) Normal renal function
• b) Renal impairment
• c) Normal liver function
• d) Young age Answer: b) Renal impairment

32. The “Management of Pain, Agitation, and Delirium in the Critically Ill Patient” is a core unit within which Patient Care VII module?

• a) Module 1: Acute Care/Critical Care
• b) Module 2: Special Populations –Pediatrics
• c) Module 3: Complex Infectious Disease Disorders
• d) Module 5: Transplant and Oncology Answer: a) Module 1: Acute Care/Critical Care

33. What is the rationale for preferring non-benzodiazepine sedatives (propofol, dexmedetomidine) over benzodiazepines for most ICU patients?

• a) They are less expensive.
• b) Benzodiazepines are associated with better outcomes, including shorter time on the ventilator.
• c) Non-benzodiazepine sedatives are associated with better outcomes, including shorter time to extubation and decreased incidence of delirium.
• d) They have no side effects. Answer: c) Non-benzodiazepine sedatives are associated with better outcomes, including shorter time to extubation and decreased incidence of delirium.

34. Ketamine is an adjunctive analgesic that is particularly useful for pain management because of its mechanism as a(n):

• a) Mu-opioid agonist
• b) NMDA receptor antagonist
• c) Alpha-2 agonist
• d) COX-2 inhibitor Answer: b) NMDA receptor antagonist

35. A critically ill patient who is alert (RASS 0) but inattentive and has disorganized thinking would be assessed as:

• a) Not having delirium.
• b) Having delirium, according to the CAM-ICU.
• c) Being appropriately sedated.
• d) Being ready for discharge. Answer: b) Having delirium, according to the CAM-ICU.

36. The pharmacist’s role in the ABCDEF bundle includes:

• a) Leading the charge on “D” – Delirium assessment and management.
• b) Guiding the “C” – Choice of analgesia and sedation.
• c) Assisting with “A” and “B” by ensuring sedatives are stopped for trials.
• d) All of the above. Answer: d) All of the above.

37. Which statement about delirium is TRUE?

• a) It is a benign condition with no long-term consequences.
• b) It is associated with increased mortality and long-term cognitive impairment.
• c) It can only be diagnosed with a brain MRI.
• d) Hypoactive delirium is less common and less harmful than hyperactive delirium. Answer: b) It is associated with increased mortality and long-term cognitive impairment.

38. When titrating an opioid infusion for pain, the goal is to use the:

• a) Highest dose possible.
• b) Lowest effective dose for the shortest duration necessary.
• c) Same dose for every patient.
• d) Dose that achieves a RASS score of -5. Answer: b) Lowest effective dose for the shortest duration necessary.

39. A patient on a propofol infusion has green discoloration of their urine. The pharmacist recognizes this as:

• a) A sign of Propofol-Related Infusion Syndrome (PRIS).
• b) A sign of a urinary tract infection.
• c) A rare but generally benign side effect of propofol metabolites.
• d) A sign of an incompatible IV drug. Answer: c) A rare but generally benign side effect of propofol metabolites.

40. Why is routine pain assessment so important in the ICU?

• a) It is a billing requirement.
• b) Untreated pain is a significant stressor that can worsen agitation, delirium, and the physiological stress response.
• c) It allows the nurse to practice using the pain scales.
• d) It is not important in non-verbal patients. Answer: b) Untreated pain is a significant stressor that can worsen agitation, delirium, and the physiological stress response.

41. Which of the following is a risk factor for developing PRIS?

• a) Low dose of propofol for a short duration.
• b) High dose of propofol (>4 mg/kg/hr) for >48 hours.
• c) Concurrent use of benzodiazepines.
• d) Older age. Answer: b) High dose of propofol (>4 mg/kg/hr) for >48 hours.

42. The most important step in managing delirium is to:

• a) Administer a high dose of haloperidol.
• b) Identify and address the underlying cause(s).
• c) Place the patient in physical restraints.
• d) Heavily sedate the patient. Answer: b) Identify and address the underlying cause(s).

43. A patient has a RASS score of +3 (Pulls or removes tube(s) or catheter(s); aggressive). This indicates:

• a) The patient is appropriately sedated.
• b) The patient is dangerously agitated.
• c) The patient is calm and cooperative.
• d) The patient is in a coma. Answer: b) The patient is dangerously agitated.

44. The use of scheduled IV acetaminophen in the ICU is a strategy for:

• a) Reducing fever only.
• b) Multimodal analgesia to reduce opioid requirements.
• c) Treating delirium.
• d) Sedating the patient. Answer: b) Multimodal analgesia to reduce opioid requirements.

45. Which of the following is a key aspect of family engagement (“F” in the bundle) in PAD management?

• a) Restricting all family visits to prevent delirium.
• b) Involving the family in the patient’s care, such as reorientation and providing familiar comfort.
• c) Providing the family with detailed updates on billing.
• d) Asking the family to make all clinical decisions. Answer: b) Involving the family in the patient’s care, such as reorientation and providing familiar comfort.

46. Morphine has an active metabolite that can accumulate in patients with what condition?

• a) Renal impairment
• b) Hepatic impairment
• c) Heart failure
• d) Asthma Answer: a) Renal impairment

47. Which of the following is the most significant environmental factor to control to prevent delirium?

• a) Maintaining a normal sleep-wake cycle with daytime light and nighttime quiet.
• b) Keeping the television on 24 hours a day.
• c) Minimizing all human contact with the patient.
• d) Keeping the patient’s room as cold as possible. Answer: a) Maintaining a normal sleep-wake cycle with daytime light and nighttime quiet.

48. Tachyphylaxis, or a rapidly diminishing response to a drug, can be seen with which IV opioid?

• a) Morphine
• b) Hydromorphone
• c) Fentanyl
• d) Codeine Answer: c) Fentanyl

49. A patient is CAM-ICU positive. What is the pharmacist’s role?

• a) To recommend starting a benzodiazepine infusion.
• b) To review the patient’s medication list for deliriogenic drugs.
• c) To ignore the finding as it is not clinically significant.
• d) To perform a neurological exam. Answer: b) To review the patient’s medication list for deliriogenic drugs.

50. The ultimate goal of modern PAD management is to:

• a) Keep patients deeply sedated and immobile to make care easier.
• b) Use as many medications as possible.
• c) Keep patients comfortable, safe, awake, and interactive with their environment whenever possible.
• d) Eliminate the need for pharmacists in the ICU. Answer: c) Keep patients comfortable, safe, awake, and interactive with their environment whenever possible.