Final - Ch 14-18 Flashcards
What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
A.
Risk for injury R/T central nervous system stimulation.
B.
Disturbed thought processes R/T tactile hallucinations.
C.
Ineffective coping R/T powerlessness over alcohol use.
D.
Ineffective denial R/T continued alcohol use despite negative consequences.
A
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 dependence?
A.
Narcotic pain medication is contraindicated for all clients with active substance-abuse problems.
B.
Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
C.
There is no need to assess the client for substance dependence. There is an obvious PCA malfunction, because these clients have a higher pain tolerance.
D.
The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.
B
On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?
A.
Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B.
Educate the client about the biopsychosocial consequences of alcohol abuse.
C.
Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
D.
Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
C
Which client statement indicates a knowledge deficit related to substance abuse?
A.
“Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
B.
“Tolerance to heroin develops quickly.”
C.
“Flashbacks from LSD use may reoccur spontaneously.”
D.
“Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”
D
A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual’s situation?
A. Psychological dependency B. Physical dependency C. Substance dependency D. Social dependency
A
Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?
A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy
D
A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to Alcoholics Anonymous (AA), would be most appropriate for a nurse to discuss with the client during discharge teaching?
A.
After discharge, the client will immediately attend 90 AA meetings in 90 days.
B.
After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C.
After discharge, the client will incorporate family in AA attendance.
D.
After discharge, the client will seek appropriate deterrent medications through AA.
A
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 24 hours. When the nurse reports to the ED physician, which client symptom should be the nurse’s first priority?
A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration
B
Which client statement demonstrates positive progress toward recovery from substance abuse?
A.
“I have completed detox and therefore am in control of my drug use.”
B.
“I will faithfully attend Narcotic Anonymous (NA) when I can’t control my carvings.”
C.
“As a church deacon, my focus will now be on spiritual renewal.”
D.
“Taking those pills got out of control. It cost me my job, marriage, and children.”
D
A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s rationale for this intervention?
A. To assess for emotional strength. B. To assess for Wernicke-Korsakoff syndrome. C. To assess for tachycardia. D. To assess for fine tremors.
D
Upon admission to an inpatient treatment facility for symptoms of alcohol withdrawal, a client states, “I haven’t eaten in 3 days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?
A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping
C
A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?
A.
“I’m not going to use heroin ever again. I know I’ve got the willpower to do it this time.”
B.
“I cannot control my use of heroin. It’s stronger than I am.”
C.
“I’m going to get all my children back. They need their mother.”
D.
“Once I deal with my childhood physical abuse, recovery should be easy.”
B
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?
A.
“Why do you assume responsibility for his behaviors?”
B.
“Codependency is a typical behavior of spouses of alcoholics.”
C.
“Your husband needs to deal with the consequences of his drinking.”
D.
“Do you understand what the term enabler means?”
C
Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?
A.
Haloperidol (Haldol) and fluoxetine (Prozac)
B.
Carbamazepine (Tegretol) and donepezil (Aricept)
C.
Disulfiram (Antabuse) and lorazepan (Ativan)
D.
Chlordiazepoxide (Librium) and phenytoin (Dilantin)
D
During group therapy, a client diagnosed with chronic alcohol dependence states, “I would not have boozed it up if my wife hadn’t been nagging me all the time to get a job. She never did think that I was good enough for her.” How should a nurse interpret this statement?
A.
The client is using denial by avoiding responsibility.
B.
The client is using displacement by blaming his wife.
C.
The client is using rationalization to excuse his alcohol dependence.
D.
The client is using reaction formation by appealing to the group for sympathy.
C
A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
A.
The client will identify one person to turn to for support.
B.
The client will give up all old drinking buddies.
C.
The client will be able to verbalize the effects of alcohol on the body.
D.
The client will correlate life problems with alcohol use.
D
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?
A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL
B
A client has a history of drinking one pint of bourbon per day for the past 6 months. He is brought to an emergency department by family members who report that his last drink was 1 hour ago. It is now 12 a.m. When should a nurse expect this client to begin experiencing withdrawal symptoms?
A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period. C. At the beginning of the third day. D. Withdrawal is individualized and cannot be predicted.
A
A client diagnosed with depression and substance abuse 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?
A.
Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
B.
Sedative-hypnotics are expensive and have numerous side effects.
C.
Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
D.
Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.
A
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?
A. Assess for medication noncompliance. B. Note escalating behaviors and intervene immediately. C. Interpret attempts at communication. D. Assess triggers for bizarre, inappropriate behaviors.
B
A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse’s teaching?
A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader
C
A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing response?
A.
“Your child has a chemical imbalance of the brain, which leads to altered thoughts.”
B.
“Your child’s hallucinations are caused by medication interactions.”
C.
“Your child has too little serotonin in the brain, causing delusions and hallucinations.”
D.
“Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”
A
Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing response?
A.
“Tell him to stop discussing the voices.”
B.
“Ignore what he is saying, while attempting to discover the underlying cause.”
C.
“Focus on the feelings generated by the hallucinations and present reality.”
D.
“Present objective evidence that the voices are not real.”
C
A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, “Do you receive special messages from certain sources, such as the television or radio?” For which potential symptom of this disorder is the nurse assessing?
A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference
D
