ch 35 Flashcards
The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient makes which statement?
a. “I go to meetings once a day and still drink.”
b. “My family and friends have been avoiding me lately.”
c. “I don’t have a problem with alcohol. I can quit anytime I want to.”
d. “I know it will be hard to quit, but I am willing to try.”
ANS: C
The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.
A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. Which condition should the nurse suspect?
a. Alcohol-induced psychosis
b. Delirium tremens (DTs)
c. Neurologic injury related to a fall
d. Posttraumatic stress reaction
ANS: B
Beginning 6–9 hours after the last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.
To prevent Wernicke’s encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications?
a. Benzodiazepine
b. Thiamine and B complex
c. Vitamins C and D3
d. Klonopin
ANS: B
The B vitamins will prevent or reverse Wernicke’s if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.
The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the highest priority for this patient?
a. Describe how the alcohol is causing the withdrawal effects.
b. Leave the patient by him/herself so as not to cause agitation.
c. Promote a safe, calm, and comfortable environment.
d. Refer the patient to an alcohol-abuse counselor.
ANS: C
The main priority is the patient’s safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.
The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with delirium tremens (DTs) and determines that the communication was nontherapeutic. What is the nurse’s next priority?
a. Encourage the patient to think of ways to change environmental triggers to abuse
substances.
b. Ask the patient what methods they think would work and encourage participating
in self-help groups.
c. Notify provider to obtain order for oxazepam and vitamin B infusion.
d. Notify provider to obtain order for CT scan and psychological consult.
ANS: C
The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions. Oxazepam and vitamin B are the two therapies that work for DTs.
A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. What is the most appropriate question the nurse should ask the patient’s friend?
a. “Does he take amphetamines or uppers?”
b. “Has he ever used LSD?”
c. “Have you two been out of the country in the last 2 days?”
d. “Is he using any opioids such as heroin?”
ANS: D
The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.
During history-taking, a patient tells the nurse that he is addicted to alprazolam and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. Which disorder should the nurse suspect?
a. Stress reaction
b. Delirium tremens
c. Overdose
d. Relapse
ANS: A
Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.
Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.)
a. Educating the patient on the physical damage the substance is causing
b. Encouraging the patient to think of ways to change environmental triggers to
abuse substances
c. Asking the patient how they think substance abuse affects their family life
d. Explaining to the patient that substance abuse affects everyone in the family and
give examples
e. Asking the patient what methods they think would work and encouraging
participating in self-help groups
ANS: B, C, E
Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.
The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram when the nurse reads in the health record that the patient is also taking which of the following? (Select all that apply.)
a. Blood thinners
b. Diphenhydramine
c. Alcohol
d. Penicillin
e. Mouthwash
ANS: A, C, E
Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.
