- A patient diagnosed with alcohol use disorder asks, “How will Alcoholics Anonymous (AA) help me?” Select the nurse’s best response.
a.
“The goal of AA is for members to learn controlled drinking with the support of a higher power.”
b.
“An individual is supported by peers while striving for abstinence one day at a time.”
c.
“You must make a commitment to permanently abstain from alcohol and other drugs.”
d.
“You will be assigned a sponsor who will plan your treatment program.”
ANS: B
Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support fr
- A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:
0200: 118/78 mm Hg and 72 beats/minute
0400: 126/80 mm Hg and 76 beats/minute
0600: 128/82 mm Hg and 72 beats/minute
0800: 132/88 mm Hg and 80 beats/minute
1000: 148/94 mm Hg and 96 beats/minute
What is the nurse’s priority action?
a.
Force fluids.
b.
Begin the detox protocol.
c.
Obtain a clean-catch urine sample.
d.
Place the patient in a vest-type restraint.
ANS: B
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.
3. A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurological d. Hepatic
ANS: B
Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority.
- A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” Select the most accurate assessment of this situation. The patient
a.
is attempting to obtain attention by manipulating staff.
b.
may have sustained a head injury before admission.
c.
has symptoms of alcohol withdrawal delirium.
d.
is having an acute psychosis.
ANS: C
Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.
5. A patient admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury
ANS: D
The patient’s clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care.
- A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n)
a.
narcotic analgesic, such as hydromorphone.
b.
sedative, such as lorazepam or chlordiazepoxide.
c.
antipsychotic, such as olanzapine or thioridazine.
d.
monoamine oxidase inhibitor antidepressant, such as phenelzine.
ANS: B
Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.
7. A hospitalized patient diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids
ANS: B
One-on-one supervision is necessary to promote physical safety until sedation reduces the patient’s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.
- A patient diagnosed with alcohol use disorder says, “Drinking helps me cope with being a single parent.” Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively?
a.
“Sooner or later, alcohol will kill you. Then what will happen to your children?”
b.
“I hear a lot of defensiveness in your voice. Do you really believe this?”
c.
“If you were coping so well, why were you hospitalized again?”
d.
“Tell me what happened the last time you drank.”
ANS: D
The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient.
- A patient asks for information about AA. Select the nurse’s best response. “AA is a
a.
form of group therapy led by a psychiatrist.”
b.
self-help group for which the goal is sobriety.”
c.
group that learns about drinking from a group leader.”
d.
network that advocates strong punishment for drunk drivers.”
ANS: B
AA is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.
- Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? The patient
a.
rarely drinks alcohol.
b.
has a high tolerance to alcohol.
c.
has been treated with disulfiram (Antabuse).
d.
has ingested both alcohol and sedative drugs recently.
ANS: B
A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol level of 300 mg/dL (0.30 g/dL). The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient’s body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.
11. A patient admitted to an alcohol rehabilitation program tells the nurse, “I’m actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening.” The patient is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization
ANS: A
Minimizing one’s drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one’s own personality.
12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine b. Methadone c. Disulfiram d. Naltrexone
ANS: D
Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.
- During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, “After this treatment program, I think everything will be all right.” Which remark by the nurse will be most helpful to the spouse?
a.
“While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol.”
b.
“It will be important for you to structure life to avoid as much stress as you can and provide social protection.”
c.
“Addiction is a lifelong disease of self-destruction. You will need to observe your spouse’s behavior carefully.”
d.
“It is good that you are supportive of your spouse’s sobriety and want to help maintain it.”
ANS: A
During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.
- The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should
a.
provide long-term care for the patient in a residential facility.
b.
withdraw the patient from cannabis, then treat the schizophrenia.
c.
consider each diagnosis primary and provide simultaneous treatment.
d.
first treat the schizophrenia, then establish goals for substance abuse treatment.
ANS: C
Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.
15. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational
ANS: A
Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.
16. Which features should be present in a therapeutic milieu for a patient experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging
ANS: A
Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a “bad trip.”
- When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred?
a.
Tolerance has developed.
b.
Antagonistic effects are evident.
c.
Metabolism of the alcohol is now delayed.
d.
Pharmacokinetics of the alcohol have changed.
ANS: A
Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.
18. At a meeting for family members of alcoholics, a spouse says, “I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work.” The nurse assesses these comments as a. codependence. b. assertiveness. c. role reversal. d. homeostasis.
ANS: A
Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario.
- In the emergency department, a patient’s vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. Select the priority outcome.
a.
The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization.
b.
Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute.
c.
The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department.
d.
Within 6 hours, the patient’s breath sounds will be clear bilaterally and throughout lung fields.
ANS: B
The correct short-term outcome is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient’s respirations are slow and shallow, but there is no evidence of congestion.
- Family members of an individual undergoing a residential alcohol rehabilitation program ask, “How can we help?” Select the nurse’s best response.
a.
“Alcoholism is a lifelong disease. Relapses are expected.”
b.
“Use search and destroy tactics to keep the home alcohol free.”
c.
“It’s important that you visit your family member on a regular basis.”
d.
“Make your loved one responsible for the consequences of behavior.”
ANS: D
Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.
21. Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability.
ANS: D
The individual must have completed withdrawal and achieved physiological stability before he or she is able to address any of the other treatment goals
22. A patient diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program
ANS: D
Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, become self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.
23. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.
ANS: A
An overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.
25. A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes a. cross-tolerance. b. substance abuse. c. substance addiction. d. substance intoxication.
ANS: C
Nicotine meets the criteria for a “substance,” the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.
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Chapter 115
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Chapter 217
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Chapter 327
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Chapter 428
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Chapter 522
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Chapter 626
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Chapter 728
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Chapter 822
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Chapter 930
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Chapter 101
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Chapter 110
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Ch. 12-V30
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Ch. 1328
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Ch.20-12-T17
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Ch.20-23-T28
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EXAM 263
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Chapter 19- Sleep Wake Disorders25
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Chapter 25- V28
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Ch. 27-V28
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Chapter 2823
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Chapter 29 v24
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Chapter 32- V29
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Chapter 17- T26
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Chapter 24- T30
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Chapter 25- T30
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Chapter 26-T30
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Chapter 28-T17
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Chapter 29-T15
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Chapter 35-T16
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Chapter 1535
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Chapter 2234
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Chapter 2332
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Chapter 3134
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Chapter 1128
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Chapter 2121
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chapter 1829
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source 130
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Source 218
