alcohol withdrawal Flashcards
Your patient is starting on disulfiram (Antabuse) for alcohol withdrawal. What is the highest priority for this patient?
A.Social reintegration
B.Learning about the disease
C.Remaining abstinent
D.Remaining in rehab
C - The priority for the patient taking disulfiram (Antabuse) is to remain abstinent. Antabuse reacts with alcohol to cause adverse effects, which is why it is given to alcoholics. The other three options are important but can not occur without option C.
You are caring for a patient who complains of sexual dysfunction. The patient was admitted for alcohol dependence. What education should you provide this patient on sexual dysfunction and alcohol abuse?
Alcohol abuse increases desire and performance ability.
Alcohol abuse leads to headaches and too-tired syndrome.
Alcohol abuse leads to hyperarousal and premature ejaculation.
Alcohol abuse decreases desire and ability to perform.
D - Alcohol abuse leads to decreased desire for sex and decreased ability to perform. The most common forms of sexual dysfunction with alcohol abuse are decreased pleasure, decreased ability to perform, decreased sexual arousal and anxiety about performance.
Your patient stopped drinking abruptly and now complains of feeling wired and being on pins and needles. What should your next intervention be?
Monitor the patient for other symptoms.
Determine the time of last drink, and assess the patient for other signs and symptoms of withdrawal.
Assess the patient for all current substance use patterns, including time of last usage and withdrawal.
Notify the physician to get an order for stimulate medication.
C - You would want to assess for all current substance use patterns, including time of last usage and assess for withdrawal signs and symptoms. The patient is displaying signs of withdrawal and will require treatment before he goes into delirium tremors, which can become life threatening.
Which assessment finding would alert the nurse to ask the patient about alcohol use?
a. Low blood pressure
b. Decreased heart rate
c. Elevated temperature
d. Abdominal tenderness
ANS: D Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in patients with chronic alcohol use. The other problems are not associated with alcohol abuse
A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11 mg%). Which action by the nurse is most appropriate?
a. Avoid the use of IV fluids.
b. Maintain the patient on NPO status.
c. Administer acetaminophen for headache.
d. Monitor frequently for anxiety, hyperreflexia, and sweating
ANS: D
The patient’s assessment data indicate probable physiologic dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, hyperreflexia, and sweating, which could be life threatening. Acetaminophen is not recommended because it is metabolizedby the liver. IV thiamine and IV glucose solutions usually are given to intoxicated patients to prevent Wernicke’s encephalopathy, and there is no indication that the patient should be NPO
An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing emergency surgery. What will the nurse expect the patient to need during the perioperative period?
a. An increased dose of the general anesthetic medication
b. Frequent monitoring for bleeding and respiratory complications
c. Interventions to prevent withdrawal symptoms within a few hours
d. Stimulation every hour to prevent prolonged postoperative sedation
ANS: B
Patients who are intoxicated at the time of surgery are at increased risk for problems with bleeding and respiratory complications such as aspiration. In an intoxicated patient, a lower dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is likelyto occur later in the postoperative course because the medications used for anesthesia, sedation, and pain will delay withdrawal symptoms. The patient should be monitored frequently for oversedation but does not need to be stimulated.
A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is most appropriate?
a. Insert an IV line and infuse fluids.
b. Promote oral intake to 3000 mL/day.
c. Provide a quiet, well-lit environment.
d. Administer opioids to provide sedation
ANS: C The patient’s symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible.
A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want anymore treatment. I have things that I have to do right away.” The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. The most important nursing action is to:
A Restrain the client until the physician can be reached
B Call security to block all areas
C Tell the client that the client cannot return to this hospital again if the client leaves now.
D Call the nursing supervisor.
D Call the nursing supervisor.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse “I should get out of this bad situation.” The most helpful response by the nurse would be:
A “I agree with you. You should get out of this situation.”
B “What do you find difficult about this situation?”
C “Why don’t you tell your husband about this?”
D “This is not the best time to make that decision.”
B “What do you find difficult about this situation?”
Nurse Wilma is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in:
A abdominal cramps and diarrhea.
B drowsiness and decreased respiration.
C flushing, vomiting, and dizziness.
D increased pulse and blood pressure
C flushing, vomiting, and dizziness.
Select the appropriate interventions for caring for the client in alcohol withdrawal.
A Monitor vital signs
B Provide stimulation in the environment
C Maintain NPO status
D Provide reality orientation as appropriate
E Address hallucinations therapeutically
A D E
The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors?
A Hypertension, changes in LOC, hallucinations
B Hypotension, ataxia, hunger
C Stupor, agitation, muscular rigidity
D Hypotension, coarse hand tremors, agitation
A
The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group when she hears the wife say:
A “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”
B “I no longer feel that I deserve the beatings my husband inflicts on me.”
C “I can tolerate my husband’s destructive behavior now that I know they are common with alcoholics.”
D “I enjoy attending the meetings because they get me out of the house and away from my husband.”
B
Ryan who is a chronic alcohol abuser is being assessed by Nurse Gina. Which problems are related to thiamin deficiency?
A Cardiovascular symptoms, such as decreased hemoglobin and hematocrit levels
B CNS symptoms, such as ataxia and peripheral neuropathy
C Gastrointestinal symptoms, such as nausea and vomiting
D Respiratory symptoms, such as cough and sore throat
B
Nurse Rob has observed a co worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co worker?
A Ignore the co worker’s behavior, and frequently assess the clients assigned to the co worker.
B Make general statements about safety issues at the next staff meeting.
C Report the coworker’s behavior to the appropriate supervisor.
D Warn the co worker that this practice is unsafe.
C
