Ch.14

Question 1

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
2. Risk for injury R/T central nervous system stimulation
3. Disturbed thought processes R/T tactile hallucinations
4. Ineffective coping R/T powerlessness over alcohol use
5. Ineffective denial R/T continued alcohol use despite negative consequences

Answer 1

1. Risk for injury R/T central nervous system stimulation

Question 2

2. A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts
   within a 30-minute period. Which is the best rationale for assessing this client for substance
   addiction?
3. Narcotic pain medication is contraindicated for all clients with active substance use disorders.
4. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to
   analgesics and require increased doses to achieve effective pain control.
5. There is no need to assess the client for substance addiction. There is an obvious PCA
   malfunction, because these clients have a higher pain tolerance.
6. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

Answer 2

2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to
   analgesics and require increased doses to achieve effective pain control.

Question 3

3. On the first day of a client’s alcohol detoxification, which nursing intervention should take
   priority?
4. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days.
5. Educate the client about the biopsychosocial consequences of alcohol abuse.
6. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
7. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

Answer 3

3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.

Question 4

4. Which client statement indicates a knowledge deficit related to a substance use disorder?
5. “Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
6. “Tolerance to heroin develops quickly.”
7. “Flashbacks from LSD use may reoccur spontaneously.”
8. “Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”

Answer 4

4. “Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”

Question 5

5. A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the
   past year. Which term should a nurse use to best describe this individual’s situation?
6. Psychological addiction
7. Physical addiction
8. Substance induced disorder
9. Social induced disorder

Answer 5

1. Psychological addiction

Question 6

6. Which term should a nurse use to describe the administration of a central nervous system
   (CNS) depressant during the substance induced disorder of alcohol withdrawal?
7. Antagonist therapy
8. Deterrent therapy
9. Codependency therapy
10. Substitution therapy

Answer 6

4. Substitution therapy

Question 7

7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient
   treatment facility after detoxification. Which client outcome, related to AA, would be most
   appropriate for a nurse to discuss with the client during discharge teaching?
8. After discharge, the client will immediately attend 90 AA meetings in 90 days.
9. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
10. After discharge, the client will incorporate family in AA attendance.
11. After discharge, the client will seek appropriate deterrent medications through AA

Answer 7

1. After discharge, the client will immediately attend 90 AA meetings in 90 days.

Question 8

8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by
   family members who state that the client has had nothing to drink in the last 48 hours. When the
   nurse reports to the ED physician, which client symptom should be the nurse’s first priority?
9. Hearing and visual impairment
10. Blood pressure of 180/100 mm Hg
11. Mood rating of 2/10 on numeric scale
12. Dehydration

Answer 8

2. Blood pressure of 180/100 mm Hg

Question 9

9. Which client statement demonstrates positive progress toward recovery from a substance use
   disorder?
10. “I have completed detox and therefore am in control of my drug use.”
11. “I will faithfully attend Narcotic Anonymous (NA) when I can’t control my cravings.”
12. “As a church deacon, my focus will now be on spiritual renewal.”
13. “Taking those pills got out of control. It cost me my job, marriage, and children.”

Answer 9

4. “Taking those pills got out of control. It cost me my job, marriage, and children.”

Question 10

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s
    rationale for this intervention?
11. To assess for emotional strength
12. To assess for Wernicke-Korsakoff syndrome
13. To assess for tachycardia
14. To assess for fine tremors

Answer 10

4. To assess for fine tremors

Question 11

11. A client presents with symptoms of alcohol withdrawal and states, “I haven’t eaten in three
    days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with
    dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis?
12. Knowledge deficit
13. Fluid volume excess
14. Imbalanced nutrition: less than body requirements
15. Ineffective individual coping

Answer 11

3. Imbalanced nutrition: less than body requirements

Question 12

12. A client’s wife has been making excuses for her alcoholic husband’s work absences. In
    family therapy, she states, “His problems at work are my fault.” Which is the appropriate nursing
    response?
13. “Why do you assume responsibility for his behaviors?”
14. “I think you should start to confront his behavior.”
15. “Your husband needs to deal with the consequences of his drinking.”
16. “Do you understand what the term enabler means?”

Answer 12

3. “Your husband needs to deal with the consequences of his drinking.”

Question 13

13. Which medication orders should a nurse anticipate for a client who has a history of
    benzodiazepine withdrawal delirium?
14. Haloperidol (Haldol) and fluoxetine (Prozac)
15. Carbamazepine (Tegretol) and donepezil (Aricept)
16. Disulfiram (Antabuse) and lorazepan (Ativan)
17. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

Answer 13

4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

Question 14

14. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the
    recovery process, which outcome should the nurse expect the client to initially accomplish?
15. The client will identify one person to turn to for support.
16. The client will give up all old drinking buddies.
17. The client will be able to verbalize the effects of alcohol on the body.
18. The client will correlate life problems with alcohol use.

Answer 14

4. The client will correlate life problems with alcohol use.

Question 15

15. A nurse is reviewing the stat laboratory data of a client in the emergency department. At
    what minimum blood alcohol level should a nurse expect intoxication to occur?
16. 50 mg/dL
17. 100 mg/dL
18. 250 mg/dL
19. 300 mg/dL

Answer 15

2. 100 mg/dL

Question 16

16. A client diagnosed with major depressive episode and substance use disorder has an altered
    sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why
    a nurse should encourage the client to first try nonpharmacological interventions?
17. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised
    owing to tolerance.
18. Sedative-hypnotics are expensive and have numerous side effects.
19. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
20. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant
    medications.

Answer 16

1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised
   owing to tolerance.

Question 17

17. A client diagnosed with a gambling disorder asks the nurse about medications that may be
    ordered by the client’s physician to treat this disorder. The nurse would give the client
    information on which medications?
18. Escitalopram (Lexapro) and clozapine (Clozaril)
19. Citalopram (Celexa) and olanzapine (Zyprexa)
20. Lithium carbonate (Lithobid) and sertraline (Zoloft)
21. Naltrexone (ReVia) and ziprasidone (Geodon)

Answer 17

3. Lithium carbonate (Lithobid) and sertraline (Zoloft)

Question 18

18. A nurse is assessing a pathological gambler. What would differentiate this client’s behaviors
    from the behaviors of a non-pathological gambler?
19. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological
    gamblers do not.
20. Pathological gambling occurs more commonly among women, whereas non-pathological
    gambling occurs more commonly among men.
21. Pathological gambling generally runs an acute course, whereas non-pathological gambling
    runs a chronic course.
22. Pathological gambling is not related to stress relief, whereas non-pathological gambling is
    related to stress relief.

Answer 18

1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological
   gamblers do not.

Question 19

19. A nursing instructor is teaching about the impaired nurse and the consequences of this
    impairment. Which statement by a student indicates that further instruction is needed?
20. “The state board of nursing must be notified with factual documentation of impairment.”
21. “All state boards of nursing have passed laws that, under any circumstances, do not allow
    impaired nurses to practice.”
22. “Many state boards of nursing require an impaired nurse to successfully complete counseling
    treatment programs prior to a return to work.”
23. “After a return to practice, a recovering nurse may be closely monitored for several years.”

Answer 19

2. “All state boards of nursing have passed laws that, under any circumstances, do not allow
   impaired nurses to practice.”