Chapter 19: Substance Use Disorders

Question 1

A patient diagnosed with alcoholism 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 working through a 12-step plan.”
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.”

Answer 1

ANS: B
Using the 12 steps, often referred to as “working the steps,” helps a person refrain from addictive behaviours while fostering individual change and growth. Peer support, accomplished by obtaining a sponsor prior to discharge, can increase the patient’s likelihood of attendance at 12-step meetings. The other options are incorrect.

Question 2

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/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 148/94 mm Hg and 96 beats/min
   What is the nurse’s priority action?
a.	Force fluids.
b.	Consult the health care provider.
c.	Obtain a clean-catch urine sample.
d.	Place the patient in a vest-type restraint.

Answer 2

ANS: B
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or that the patient is presently in need of restraint. Hydration will not resolve the problem.

Question 3

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority?

a. Cardiovascular
b. Respiratory
c. Neurologic
d. Hepatic

Answer 3

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. See relationship to audience response question.

Question 4

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, and diaphoretic and reports nightmares. The pulse rate is 130 beats/min. 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.

a. The patient is attempting to obtain attention by manipulating staff.
b. The patient may have sustained a head injury before admission.
c. The patient has symptoms of alcohol-withdrawal delirium.
d. The patient is having an acute psychosis.

Answer 4

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.

Question 5

A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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

Answer 5

ANS: D

The patient’s clouded sensorium, sensory perceptual distortions, and poor judgement predispose a risk for injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care.

Question 6

A hospitalized patient diagnosed with an alcohol abuse 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 which of the following?

a. A narcotic analgesic, such as hydromorphone (Dilaudid)
b. A benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium)
c. An antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril)
d. A monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil)

Answer 6

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.

Question 7

A hospitalized patient diagnosed with an alcohol abuse 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

Answer 7

ANS: B
Immediate medical attention, ongoing assessment and supervised treatment 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.

Question 8

A patient diagnosed with an alcohol abuse 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.”

Answer 8

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 defences against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient.

Question 9

A patient asks for information about Alcoholics Anonymous. Select the nurse’s best response.

a. “Alcoholics Anonymous is a form of group therapy led by a psychiatrist.”
b. “Alcoholics Anonymous is a self-help group for which the goal is sobriety.”
c. “Alcoholics Anonymous is a group that learns about drinking from a group leader.”
d. “Alcoholics Anonymous is a network that advocates strong punishment for drunk drivers.”

Answer 9

ANS:	B
Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

Question 10

Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 0.50 mg%. Considering the relationship between the behaviour and blood alcohol level, which conclusion is most probable?

a. The patient rarely drinks alcohol.
b. The patient has a high tolerance to alcohol.
c. The patient has been treated with disulfiram (Antabuse).
d. The patient has ingested both alcohol and sedative drugs recently.

Answer 10

ANS: B
A nontolerant drinker would be in coma with a blood alcohol level of 0.50 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behaviour 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.

Question 11

A patient admitted to an alcoholism 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 defence mechanism?

a. Denial
b. Projection
c. Introjection
d. Rationalization

Answer 11

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.

Question 12

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?

a. Naloxone (Targin)
b. Methadone (Metadol)
c. Disulfiram (Antabuse)
d. Naltrexone (ReVia)

Answer 12

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.

Question 13

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 behaviour carefully.”
d. “It is good that you are supportive of your spouse’s sobriety and want to help maintain it.”

Answer 13

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.

Question 14

The treatment team discusses the plan of care for a patient with concurrent disorders of schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, which of the following should the team do?

a. Provide long-term care for the patient in a residential facility
b. Withdraw the patient from cannabis, and then treat the schizophrenia
c. Consider each diagnosis primary and provide simultaneous treatment
d. First treat the schizophrenia, and then establish goals for substance abuse treatment

Answer 14

ANS: C
Patients with concurrent disorders need to receive simultaneous treatment. Patients with co-occurring disorders require longer treatment and progress is slower, but treatment may occur in the community.

Question 15

Select the most therapeutic manner for a nurse to work with a patient who is beginning treatment for alcohol addiction.

a. Empathetic, supportive
b. Skeptical, guarded
c. Cool, distant
d. Confrontational

Answer 15

ANS: A
Support and empathy assist the patient to feel safe enough to start looking at problems. Counselling 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 defences.

Question 16

Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose?

a. Simple and safe
b. Active and bright
c. Stimulating and colourful
d. Confrontational and challenging

Answer 16

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.”

Question 17

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. The pharmacokinetics of the alcohol has changed.

Answer 17

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 delayed metabolism nor antagonistic effects account for this change.

Question 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 which of the following?

a. Codependence
b. Assertiveness
c. Role reversal
d. Homeostasis

Answer 18

ANS: A
Codependence refers to participating in behaviours 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. See relationship to audience response question.

Question 19

In the emergency department, a patient’s vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory centre secondary to narcotic 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/min, and respirations at or above 12 breaths/min.
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.

Answer 19

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.

Question 20

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 behaviour.”

Answer 20

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 behaviours, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviours or are of no help.

Question 21

21. Which goal for treatment of alcoholism should the nurse address first?
    a. Learn about addiction and recovery.
    b. Develop alternate coping strategies.
    c. Develop a peer support system.
    d. Achieve physiologic stability.

Answer 21

ANS: D
The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals

Question 22

A patient 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

Answer 22

ANS: D
Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviours, develop employment skills, be self-reliant, and practise honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

Question 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.

Answer 23

ANS: A
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.

Question 24

Which of the following symptoms of withdrawal from opioids should the nurse assess?

a. Dilated pupils, tachycardia, elevated blood pressure, and elation
b. Nausea, vomiting, diaphoresis, anxiety, and hyperreflexia
c. Mood lability, incoordination, fever, and drowsiness
d. Excessive eating, constipation, and headache

Answer 24

ANS: B
The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

Question 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. Which of the following does this scenario describe?

a. Cross-tolerance
b. Substance abuse
c. Substance addiction
d. Substance intoxication

Answer 25

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.

Question 26

Which assessment findings are likely for an individual who recently injected heroin?

a. Anxiety, restlessness, paranoid delusions
b. Muscle aching, dilated pupils, tachycardia
c. Heightened sexuality, insomnia, euphoria
d. Drowsiness, constricted pupils, slurred speech

Answer 26

ANS: D
Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviours consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use. (Educators may alter this question to multiple answers if desired.)

Question 27

An adult in the emergency department states, “Everything I see appears to be waving. I am outside my body looking at myself. I think I’m losing my mind.” Vital signs are slightly elevated. Which of the following should the nurse suspect?

a. A schizophrenic episode
b. Hallucinogen ingestion
c. Opium intoxication
d. Cocaine overdose

Answer 27

ANS: B
The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about “going crazy.” Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviours. Phencyclidine (PCP) use commonly causes bizarre or violent behaviour, nystagmus, elevated vital signs, and repetitive jerking movements.

Question 28

A young woman has been admitted to hospital for use of room deodorizers as inhalants. Which is a sign of intoxication from inhaling volatile nitrites such as room deodorizers?

a. Flushing
b. Hallucinations
c. Slurred speech
d. Enhancement of sexual pleasure

Answer 28

ANS: D
A sign of intoxication from inhaling volatile nitrites such as room deodorizers is enhancement of sexual pleasure. Flushing, hallucinations, and slurred speech are signs of intoxication from inhaling organic solvents.

Question 29

A patient is thin, tense, and jittery and has dilated pupils. The patient says, “My heart is pounding in my chest. I need help.” The patient allows vital signs to be taken but then becomes suspicious and says, “You could be trying to kill me.” The patient refuses further examination. Abuse of which substance is most likely?

a. PCP
b. Heroin
c. Barbiturates
d. Amphetamines

Answer 29

ANS: D
The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behaviour. Barbiturates and heroin would result in symptoms of CNS depression.

Question 30

Select the priority outcome for a depressed patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will do which of the following?

a. State, “I know I need long-term treatment.”
b. Use denial and rationalization in healthy ways.
c. Identify constructive outlets for expression of anger.
d. Develop a trusting relationship with one staff member.

Answer 30

ANS: A
The correct option refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

Question 31

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse’s best first action?

a. Perform a thorough assessment of the patient.
b. Verify that security services are immediately available.
c. Self-assess personal attitude, values, and beliefs about this health problem.
d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

Answer 31

ANS: C
The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one’s own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

Question 32

Which of the following would be part of the treatment plan for a person experiencing alcohol overdose? Select all that apply.

a. Monitor vital signs every 5 minutes
b. Monitor for respiratory depression
c. Maintain hydration with IV fluids
d. Administer antipsychotic medication
e. Administer oxygen

Answer 32

ANS: B, C, E
Correct aspects of the treatment plan for this patient would be to monitor for respiratory depression, maintain hydration with IV fluids, and administer oxygen. Vital signs are to be monitored; however every 5 minutes is too often—every 15 minutes is sufficient. There is no indication that the patient requires an antipsychotic medication.

Question 33

The nurse can assist a patient to prevent substance abuse relapse by doing which of the following? Select all that apply.

a. Rehearsing techniques to handle anticipated stressful situations
b. Advising the patient to accept residential treatment if relapse occurs
c. Assisting the patient to identify life skills needed for effective coping
d. Advising isolating self from significant others until sobriety is established
e. Informing the patient of physical changes to expect as the body adapts to functioning without substances

Answer 33

ANS: A, C, E
Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

Question 34

A patient took a large quantity of phenylcyclohexyl piperidine. Priority nursing and medical measures include which of the following? Select all that apply.

a. Administration of naloxone (Narcan)
b. Vitamin B12 and folate supplements
c. Restoring nutritional integrity
d. Management of heart rate
e. Environmental safety

Answer 34

ANS: D, E
Care of patients who have taken phenylcyclohexyl piperidine (PCP) is similar to the care of those who have used other stimulants. Tachycardia and chest pain are common when a patient has used PCP. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behaviour or paranoia (or both); therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

Question 35

What behaviours would the nurse expect to assess in a nontolerant drinker with a blood alcohol level of 0.20 mg%? Select all that apply.

a. Ataxia
b. Staggering
c. Confusion
d. Stupor
e. Emotional liability

Answer 35

ANS: A, B, E
The nurse would see staggering, ataxia, and emotional lability in a nontolerant drinker with a blood alcohol level (BAL) of 0.20 mg%. Confusion and stupor are seen with BALs of 0.30 mg% and higher.