Chapter 22 Flashcards
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 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.”
B: Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.
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.
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 is presently in need of restraint. Hydration will not resolve the problem.
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
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.
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/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. 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.
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.
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
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 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 a(n):
a. narcotic analgesic, such as hydromorphone (Dilaudid).
b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).
c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril).
d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).
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.
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
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 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.”
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 Alcoholics Anonymous. Select the nurse’s best response. “Alcoholics Anonymous 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.”
B: Alcoholics Anonymous (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 ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior 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.
B: A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. 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.
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 defense mechanism?
a. Denial
b. Projection
c. Introjection
d. Rationalization
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.
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?
a. Bromocriptine (Parlodel)
b. Methadone (Dolophine)
c. Disulfiram (Antabuse)
d. Naltrexone (ReVia)
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.”
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.
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.
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
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.
