mental-substance 8q 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. Risk for injury R/T central nervous system stimulation
The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.
A nurse evaluates a clients 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 use disorder?
A. Narcotic pain medication is contraindicated for all clients with active substance-use problems.
B. Clients who are regularly using 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 use disorder. There is an obvious PCA malfunction.
D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.
B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessens the clients response to another drug.
On the first day of a clients 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. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening
Which client statement indicates a knowledge deficit related to substance use?
A. Although its 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. Its essentially harmless.
D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.
The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have potentially harmful effects. Cannabis is the second most widely abused drug in the United States.
A lonely, depressed divorce has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individuals situation?
A. The individual is experiencing psychological addiction. B. The individual is experiencing physical addiction.
C. The individual is experiencing substance addiction.
D. The individual is experiencing social addiction.
A. The individual is experiencing psychological addiction.
The nurse should use the term psychological addiction to best describe this clients situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.
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. Substitution therapy
A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life- threatening symptoms that occur because of the rebound reaction of the central nervous system.
A client diagnosed with chronic alcohol use disorder 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. After discharge, the client will immediately attend 90 AA meetings in 90 days.
The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.
. 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. Which client symptom should the nurse immediately report to the ED physician?
A. Antecubital bruising
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale D. Dehydration
B. Blood pressure of 180/100 mm Hg
The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.
Which client statement demonstrates positive progress toward recovery from a substance use disorder?
A. I have completed detox and therefore am in control of my drug use.
B. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings.
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. Taking those pills got out of control. It cost me my job, marriage, and children.
A client who takes responsibility for the consequences of substance use is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process, in which he or she accepts the fact that substance use causes problems.
A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses 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. To assess for fine tremors
The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.
Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) 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. Imbalanced nutrition: less than body requirements
The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.
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 drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client?
A. Im not going to use heroin ever again. I know Ive got the willpower to do it this time.
B. I cannot control my use of heroin. Its stronger than I am.
C. Im 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. I cannot control my use of heroin. Its stronger than I am.
A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over
A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. 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. Your husband needs to deal with the consequences of his drinking.
The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited.
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 lorazepam (Ativan)
D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)
D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)
The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.
During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if my wife hadnt 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. The client is using rationalization to excuse his alcohol dependence.
The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.
A nurse is interviewing a client in an outpatient drug treatment 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. The client will correlate life problems with alcohol use.
To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.
A nurse is reviewing STAT laboratory data of a client presenting 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. 100 mg/dL
The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.
A client diagnosed with depression 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?
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. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence
A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem?
A. Ineffective coping R/T unresolved anxiety AEB substance abuse
B. Anxiety R/T poor sleep AEB difficulty falling asleep
C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
D. Risk for injury R/T addiction to Librium
C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.
A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess?
A. Gross tremors, delirium, hyperactivity, and hypertension
B. Disorientation, peripheral neuropathy, and hypotension
C. Oculogyric crisis, amnesia, ataxia, and hypertension
D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension
A. Gross tremors, delirium, hyperactivity, and hypertension
Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.
A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse?
A. Alcohol poisoning
B. Cardiovascular accident (CVA)
C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine
C. A reaction to disulfiram (Antabuse)
Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.
A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse?
A. This medication will help you maintain your abstinence.
B. This medication will cause uncomfortable symptoms if you combine it with alcohol.
C. This medication will decrease the effect alcohol has on your body.
D. This medication will lower your risk of experiencing a complicated withdrawal.
A. This medication will help you maintain your abstinence.
Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.
