Chapter 22 - Substance-Related and Addictive Disorders

Question 1

A Client diagnosed with alcohol use disorder asks, “How will Alcoholics Anonymous (AA) help me?” What is 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.”

Answer 1

b. “An individual is supported by peers while striving for abstinence one day at a time.”

Question 2

A nurse reviews vital signs for a client 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/minute
0400: 126/80 mm Hg and 76 beats/minute
0600: 128/82 mm Hg and 72 beats/minute
0800: 132/88 mm Hg and 80 beats/minute
1000: 148/94 mm Hg and 96 beats/minute
What is the nurse’s priority action?

a. Force fluids.
b. Begin the detox protocol.
c. Obtain a clean-catch urine sample.
d. Place the Client in a vest-type restraint

Answer 2

b. Begin the detox protocol.

Question 3

A nurse cares for a client experiencing an opioid overdose. Which focused assessment has the highest priority?

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

Answer 3

b. Respiratory

Question 4

A client admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The client is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The client shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” What is the most accurate assessment of this situation?

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

Answer 4

c. The client has symptoms of alcohol withdrawal delirium.

Question 5

A client admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The client 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

d. Risk for injury

Question 6

A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe what medication intervention?

a. narcotic analgesic, such as hydromorphone.
b. sedative, such as lorazepam or chlordiazepoxide.
c. antipsychotic, such as olanzapine or thioridazine.
d. monoamine oxidase inhibitor antidepressant, such as phenelzine

Answer 6

b. sedative, such as lorazepam or chlordiazepoxide.

Question 7

A hospitalized Client diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The client is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?

a. Check the client every 15 minutes
b. One-on-one supervision
c. Keep the room dimly lit
d. Force fluids

Answer 7

b. One-on-one supervision

Question 8

A client diagnosed with alcohol use disorder says, “Drinking helps me cope with being a single parent.” Which therapeutic response by the nurse would help the client 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

d. “Tell me what happened the last time you drank.”

Question 9

A Client asks for information about alcoholics anonymous (AA). What is the nurse’s best response? “

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

Answer 9

b. AA is a self-help group for which the goal is sobriety.”

Question 10

Police bring a client to the emergency department after an automobile accident. The client demonstrates poor coordination and slurred speech, but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship
between the assessment findings and blood alcohol level, which conclusion is most probable?

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

Answer 10

b. The client has a high tolerance to alcohol.

Question 11

A client admitted to an alcohol 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 client is using which defense mechanism?

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

Answer 11

a. Denial

Question 12

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

a. Bromocriptine
b. Methadone
c. Disulfiram
d. Naltrexone

Answer 12

d. Naltrexone

Question 13

During the third week of treatment, the spouse of a client 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.”

Answer 13

a. “While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol.”

Question 14

The treatment team discusses the plan of care for a client diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should consider what intervention?

a. provide long-term care for the client in a residential facility.
b. withdraw the client 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.

Answer 14

c. consider each diagnosis primary and provide simultaneous treatment.

Question 15

What is the most therapeutic characteristics for a nurse working with a client beginning treatment for alcohol addiction to present?

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

Answer 15

a. Empathetic, supportive

Question 16

Which features should be present in a therapeutic milieu for a client experiencing a hallucinogen overdose?

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

Answer 16

a. Simple and safe

Question 17

When a client 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. Pharmacokinetics of the alcohol have changed

Answer 17

a. Tolerance has developed.

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 what?

a. codependence.
b. assertiveness.
c. role reversal.
d. homeostasis.

Answer 18

a. codependence.

Question 19

In the emergency department, a client’s vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. What is the priority outcome?

a. The client 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/minute, and respirations at or above 12 breaths/minute.
c. The client 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 client’s breath sounds will be clear bilaterally and throughout lung fields.

Answer 19

b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute.

Question 20

Family members of an individual undergoing a residential alcohol rehabilitation program ask, “How can we help?” What is 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 behavior.”

Answer 20

d. “Make your loved one responsible for the consequences of behavior.”

Question 21

Which goal for treatment of alcohol use disorder should the nurse address first?

a. Learn about addiction and recovery.
b. Develop alternate coping strategies.
c. Develop a peer support system.
d. Achieve physiological stability.

Answer 21

d. Achieve physiological stability.

Question 22

A client diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the client 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

d. Residential program

Question 23

What is the priority nursing intervention when caring for a client after an overdose of amphetamines?

a. Monitor vital signs.
b. Observe for depression.
c. Awaken the client every 15 minutes.
d. Use warmers to maintain body temperature.

Answer 23

a. Monitor vital signs.

Question 24

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

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

b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.

Question 25

A client has smoked two packs of cigarettes daily for many years. When the client tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario should be described using which term?

a. cross-tolerance.
b. substance abuse.
c. substance addiction.
d. substance intoxication.

Answer 25

c. substance addiction.

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

d. Drowsiness, constricted pupils, slurred speech

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.” When vital signs are slightly elevated what should the nurse suspect?

a. a schizophrenic episode.
b. hallucinogen ingestion.
c. opium intoxication.
d. cocaine overdose.

Answer 27

b. hallucinogen ingestion.

Question 28

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information?

a. Substance Abuse and Mental Health Services Administration (SAMHSA)
b. Institute of Medicine (IOM)–National Research Council
c. National Council of State Boards of Nursing (NCSBN)
d. American Society of Addictions Medicine

Answer 28

a. Substance Abuse and Mental Health Services Administration (SAMHSA)

Question 29

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

a. phencyclidine (PCP)
b. Heroin
c. Barbiturates
d. Amphetamines

Answer 29

d. Amphetamines

Question 30

What is the priority outcome for a client completing the fourth alcohol detoxification program in the past year?

a. Prior to discharge, the client will state, “I know I need long-term treatment.”
b. Prior to discharge, the client will use denial and rationalization in healthy ways.
c. Prior to discharge, the client will identify constructive outlets for expression of anger.
d. Prior to discharge, the client will develop a trusting relationship with one staff member.

Answer 30

a. Prior to discharge, the client will state, “I know I need long-term treatment.”

Question 31

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

a. Perform a thorough assessment of the client.
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

c. Self-assess personal attitude, values, and beliefs about this health problem.

Question 32

A client undergoing alcohol rehabilitation decides to begin disulfiram therapy. Client teaching should include the need to (Select all that apply.)

a. avoid aged cheeses.
b. avoid alcohol-based skin products.
c. read labels of all liquid medications.
d. wear sunscreen and avoid bright sunlight.
e. maintain an adequate dietary intake of sodium.
f. avoid breathing fumes of paints, stains, and stripping compounds.

Answer 32

b. avoid alcohol-based skin products.
c. read labels of all liquid medications.
f. avoid breathing fumes of paints, stains, and stripping compounds.

Question 33

The nurse can assist a client to prevent substance abuse relapse by (Select all that apply.)

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

Answer 33

a. rehearsing techniques to handle anticipated stressful situations.
c. assisting the client to identify life skills needed for effective coping.
e. informing the client of physical changes to expect as the body adapts to functioning without substances.

Question 34

After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.)

a. Refer the nurse to a peer assistance program.
b. Confront the nurse in the presence of a witness.
c. Immediately terminate the nurse’s employment.
d. Relieve the nurse of responsibilities for client care.
e. Require the nurse to undergo immediate drug testing.

Answer 34

a. Refer the nurse to a peer assistance program.
d. Relieve the nurse of responsibilities for client care.

Question 35

A new client beginning an alcohol rehabilitation program says, “I’m just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening.” Which responses by the nurse will be most therapeutic? (Select all that apply.)

a. “I see,” and use interested silence.
b. “I think you are drinking more than you report.”
c. “Social drinkers have one or two drinks, once or twice a week.”
d. “You describe drinking steadily throughout the day and evening.”
e. “Your comments show denial of the seriousness of your problem.”

Answer 35

c. “Social drinkers have one or two drinks, once or twice a week.”
d. “You describe drinking steadily throughout the day and evening.”