UNIT J Flashcards
A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge?
a. The adolescent and parents create and agree to a behavioral contract with rules,
rewards, and consequences.
b. The adolescent identifies friends in the home community who are a positive
influence.
c. Temporary placement is arranged with a foster family until the parents complete a
parenting skills class.
d. The adolescent experiences no anger and frustration for 1 week.
ANS: A
The adolescent and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The adolescent will continue to experience anger and frustration. The adolescent and parents must continue with family therapy to work on boundary and communication issues. It is not necessary to separate the adolescent from the family to work on these issues. Separation is detrimental to the healing process. While it is helpful for the adolescent to identify peers who are a positive influence, it is more important for behavior to be managed for an adolescent diagnosed with a CD.
A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, “We can’t manage our teenager.” The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent’s behavior?
a. Attention deficit hyperactivity disorder (ADHD)
b. Posttraumatic stress disorder (PTSD)
c. Intermittent explosive disorder
d. CD
ANS: D
CDs are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. Criteria for ADHD and PTSD are not met in the scenario.
A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic?
a. Planned ignoring
b. Establish firm limits
c. Neutrally permit refusals
d. Coaxing to gain compliance
ANS: B
Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teen’s thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, ignoring, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which type of therapy might promote the greatest change in the adolescent’s behavior?
a. Family therapy
b. Bibliotherapy
c. Play therapy
d. Art therapy
ANS: A
Family therapy focuses on problematic family relationships and interactions. The patient has identified problems within the family. Play therapy is more appropriate for younger patients. Art therapy and bibliotherapy would not focus specifically on the identified problem.
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which nursing diagnosis is most applicable?
a. Disturbed personal identity related to acting out as evidenced by prostitution
b. Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents
c. Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out
d. Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another
ANS: C
The patient demonstrates a failure to follow age-appropriate social norms and an inability to problem solve by using adaptive behaviors to meet life’s demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient never mentioned hopelessness or disturbed personal identity. The problem relates to the patient’s perceptions of parental behavior rather than the actual behavior.
A 12-year-old has engaged in bullying for several years. The parents say, “We can’t believe anything our child says.” Recently this child shot a dog with a pellet gun and set fire to a neighbor’s trash bin. The child’s behaviors support the diagnosis of
a. ADHD.
b. intermittent explosive disorder.
c. oppositional defiant disorder (ODD).
d. CD.
ANS: D
The behaviors mentioned are most consistent with criteria for CD, including aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. The behaviors are not consistent with attention deficit or oppositional defiant disorder (ODD).
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation.
a. Ignore the child’s behavior.
b. Send the child to time-out for 2 hours.
c. Take the child to the gym and engage in an activity.
d. Role-play a more appropriate behavior with the child.
ANS: C
The child’s behavior warrants an active response. Redirecting the expression of feelings into nondestructive age-appropriate behaviors, such as a physical activity, helps defuse the situation here and now. This response helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to a more restrictive measure. Role playing is appropriate after the child’s anger is defused.
An adolescent acts out in disruptive ways. When this adolescent threatens to throw a heavy pool ball at another adolescent, which comment by the nurse would set appropriate limits?
a. “Attention everyone: we are all going to the craft room.”
b. “You will be taken to seclusion if you throw that ball.”
c. “Do not throw the ball. Put it back on the pool table.”
d. “Please do not lose control of your emotions.”
ANS: C
Setting limits uses clear, sharp statements about prohibited behavior and guidance for performing a behavior that is expected. The incorrect options represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the child’s developing self-control that may be ineffective.
The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child’s plan of care will be provided by an advanced practice nurse rather than a staff nurse?
a. Leading an activity group
b. Providing positive feedback
c. Formulating nursing diagnoses
d. Dialectical behavioral therapy (DBT)
ANS: D
The advanced practice nurse role includes individual, group, and family psychotherapist;
educator of nurses, other professions, and the community; clinical supervisor; consultant to professional and nonprofessional groups; and researcher. DBT is an aspect of psychotherapy. The distracters describe actions of a nurse generalist.
Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, “I’d rather stay in my room and listen to music. It’s easier than thinking about what is happening in my family.” Which nursing diagnosis is most applicable?
a. Chronic low self-esteem related to role within the family
b. Decisional conflict related to compliance with school requirements
c. Defensive coping related to adjustment to changes in family relationships
d. Disturbed personal identity related to self-perceptions of changing family
dynamics
ANS: C
Depression is often associated with impulse control disorder. The correct nursing diagnosis refers to the patient’s dysfunctional management of feelings associated with upcoming changes to the family. The teen displays self-imposed isolation. The distracters are not supported by data in the scenario.
A child known as the neighborhood bully says, “Nobody can tell me what to do.” After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher’s computer. These behaviors support a diagnosis of
a. CD.
b. ODD.
c. intermittent explosive disorder.
d. ADHD.
ANS: B
ODD is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Loading a virus is a vindictive behavior in retribution for a poor grade. Persons with CD are aggressive against people and animals; destroy property; are deceitful; violate rules; and have impaired social, academic, or occupational functioning. There is no evidence of explosiveness or distractibility.
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurse’s initial action to defuse the situation?
a. Say to the child, “Tell me how you’re feeling right now.”
b. Take the child swimming at the facility’s pool.
c. Establish a behavioral contract with the child. d. Administer an anxiolytic medication.
ANS: B
Redirecting the expression of feelings into nondestructive, age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to measures that are more restrictive. A shouting child will not likely engage in a discussion about feelings. A behavioral contract could be considered later, but first the situation must be defused.
Parents of an adolescent diagnosed with a CD say, “We don’t know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?” Which therapy is likely to be helpful for these parents?
a. Parent–child interaction therapy (PCIT)
b. Behavior modification therapy
c. Multi-systemic therapy (MST)
d. Pharmacotherapy
ANS: A
In PCIT, the therapist sits behind one-way mirrors and coaches parents through an ear audio device while they interact with their children. The therapist can suggest strategies that reinforce positive behavior in the adolescent. The goal is to improve parenting strategies and thereby reduce problematic behavior. Behavior modification therapy may help the adolescent, but the parents are seeking help for themselves. MST is much broader and does not target the parents’ need.
An adolescent diagnosed with an impulse control disorder says, “I want to die. I spend my time getting even with people who hurt me.” When asked about a suicide plan, the adolescent replies, “I’ll jump from a bridge near my home. My father threw kittens off that bridge and they died.” Rate the suicide risk.
a. Absent
b. Low
c. Moderate d. High
ANS: D
The suicide risk is high. The child is experiencing feelings of hopelessness and helplessness. The method described is lethal, and the means to carry out the plan are available.
An adolescent diagnosed with CD has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication?
a. Second-generation antipsychotic
b. Antianxiety medication
c. Calcium channel blocker
d. -blocker
ANS: A
Medications for CD are directed at problematic behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms. Second-generation antipsychotics are likely to be prescribed. -blocking medications may help to calm individuals with intermittent explosive disorder by slowing the heart rate and reducing blood pressure. Calcium channel blockers reduce blood pressure but are not used for persons with impulse control problems. An antianxiety medication will not assist with impulse control.
An adolescent was recently diagnosed with ODD. The parents say to the nurse, “Isn’t there some medication that will help with this problem?” Select the nurse’s best response.
a. “There are no medications to treat this problem. This diagnosis is behavioral innature.”
b. “It’s a common misconception that there is a medication available to treat every
health problem.”
c. “Medication is usually not prescribed for this problem. Let’s discuss some
behavioral strategies you can use.”
d. “There are many medications that will help your child manage aggression and
destructiveness. The health care provider will discuss them with you.”
ANS: C
The parents are seeking a quick solution. Medications are generally not indicated for ODD. Comorbid conditions that increase defiant symptoms, such as ADHD, should be managed with medication, but no comorbid problem is identified in the question. The nurse should give information on helpful strategies to manage the adolescent’s behavior.
An adolescent diagnosed with a CD stole and wrecked a neighbor’s motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent’s reaction?
a. Serotonin dysregulation and increased testosterone activity impair one’s capacity
for remorse.
b. Increased neuron destruction in the hippocampus results in decreased abilities to
conform to social rules.
c. Reduced gray matter in the cortex and dysfunction of the amygdala results in
decreased feelings of empathy.
d. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.
ANS: C
Adolescents with CD have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the amygdala. This reduction may be related to aggressive behavior and deficits of empathy. The less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. People with intermittent explosive disorder may have differences in serotonin regulation in the brain and higher levels of testosterone. Neuron destruction in the hippocampus is associated with memory deficits. The occipital lobe is involved with visual stimuli but not the processing of emotions.
Which assessment findings support a diagnosis of ODD?
a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior.
b. Exhibits involuntary facial twitching and blinking; makes barking sounds.
c. Violates others’ rights; cruelty toward people or animals; steals; truancy.
d. Displays poor academic performance and reports frequent nightmares.
ANS: A
ODD is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. The distracters identify findings associated with CD, anxiety disorder, and Tourette’s syndrome.
A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient’s history support the suspected diagnosis? (Select all that apply.)
a. Family history of mental illness
b. Allergies to multiple antibiotics
c. Long history of severe facial acne
d. Father with history of alcohol abuse
e. History of an abusive relationship with one parent
ANS: A, D, E
Parents who are abusive, rejecting, or overly controlling cause a child to suffer detrimental effects. Other stressors associated with impulse control disorders can include major disruptions such as placement in foster care, severe marital discord, or a separation of parents. Substance abuse by a parent is common. Acne and allergies are not aspects of the history that relate to the behavior.
What are the primary distinguishing factors between the behavior of persons diagnosed with ODD and those with CD? The person diagnosed with (Select all that apply)
a. ODD relives traumatic events by acting them out.
b. ODD tests limits and disobeys authority figures.
c. ODD has difficulty separating from loved ones.
d. CD uses stereotypical or repetitive language.
e. CD often violates the rights of others.
ANS: B, E
Persons diagnosed with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas persons with CD frequently behave in ways that do violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with PTSD. Stereotypical language behaviors are seen in persons with autism spectrum disorders.
A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because (Select all that apply)
a. it is a vital component of implementing a behavior modification program.
b. a therapeutic alliance is the first step in a nurse’s therapeutic use of self.
c. the adolescent has demonstrated resistance to other authority figures.
d. acceptance and trust convey feelings of security for the adolescent.
e. adolescents usually relate better to authority figures than peers.
ANS: B, D
Trust is frequently an issue because the adolescent may never have had a trusting relationship with an adult. Trust promotes feelings of security and is the basis of the nurse’s therapeutic use of self. Adolescents value peer relationships over those related to authority. Rewards for appropriate behavior are the main component of behavior modification programs.
A patient diagnosed with alcohol use disorder 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.”
ANS: 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/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 patient in a vest-type restraint.
ANS: B
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. 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 experiencing an opioid overdose. Which focused assessment has the highest priority?
a. Cardiovascular
b. Respiratory
c. Neurological
d. Hepatic
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.
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/minute. 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.
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.
A patient admitted yesterday for injuries sustained while intoxicated believes insects 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
ANS: 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 alcohol use 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.
b. sedative, such as lorazepam or chlordiazepoxide.
c. antipsychotic, such as olanzapine or thioridazine.
d. monoamine oxidase inhibitor antidepressant, such as phenelzine.
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.
A hospitalized patient diagnosed with alcohol use 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
ANS: 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 alcohol use 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.”
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 defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient.
A patient asks for information about AA. Select the nurse’s best response. “AA 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.”
ANS: B
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 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? 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.
ANS: B
A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol level of 300 mg/dL (0.30 g/dL). 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 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 patient is using which defense mechanism?
a. Denial
b. Projection
c. Introjection
d. Rationalization
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.
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?
a. Bromocriptine
b. Methadone
c. Disulfiram
d. Naltrexone
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.
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.”
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.
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.
ANS: 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
ANS: 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.
Which features should be present in a therapeutic milieu for a patient experiencing a hallucinogen overdose?
a. Simple and safe
b. Active and bright
c. Stimulating and colorful
d. Confrontational and challenging
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.”
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. Pharmacokinetics of the alcohol have changed.
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 hypomagnesemia nor antagonistic effects account for this change.
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
a. codependence.
b. assertiveness.
c. role reversal.
d. homeostasis.
ANS: A
Codependence refers to participating in behaviors 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.
In the emergency department, a patient’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.
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/minute, and respirations at or above 12 breaths/minute.
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.
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.
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 behavior.”
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 behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.
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.
ANS: D
The individual must have completed withdrawal and achieved physiological stability before he or she is able to address any of the other treatment goals.
A patient diagnosed 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
ANS: D
Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, become self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.
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.
ANS: A
An 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.
Symptoms of withdrawal from opioids for which the nurse should assess include
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.
ANS: B
The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.
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. This scenario describes
a. cross-tolerance.
b. substance abuse.
c. substance addiction.
d. substance intoxication.
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.
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
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 behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.
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. The nurse should suspect
a. a schizophrenic episode.
b. hallucinogen ingestion.
c. opium intoxication.
d. cocaine overdose.
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 behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.
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
ANS: A
The SAMHSA is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.
A patient is thin, tense, 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
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 behavior. Barbiturates and heroin would result in symptoms of CNS depression.
Select the priority outcome for a patient completing the fourth alcohol detoxification program in the past year. Prior to discharge, the patient will
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.
ANS: A
The correct response recognizes 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.
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.
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.
A patient undergoing alcohol rehabilitation decides to begin disulfiram therapy. Patient 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.
ANS: B, C, F
The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.
The nurse can assist a patient to prevent substance abuse relapse by (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.
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.
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 patient care.
e. Require the nurse to undergo immediate drug testing.
ANS: A, D
Registered nurses may have personal substance use problems. The nursing supervisor should provide for safe patient care by relieving the nurse of responsibility for patient care. For those nurses experiencing addictions, there are nonpunitive alternatives to discipline programs in the form of peer assistance. Many state boards of nursing have developed an alternative to discipline program to help impaired nurses. Terminating the nurse’s employment and confronting the nurse in the presence of a witness are punitive actions. The peer assistance program will manage drug testing.
A new patient 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.”
ANS: C, D
The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.
An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of
a. delirium.
b. dementia.
c. amnestic syndrome.
d. Alzheimer’s disease.
ANS: A
Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer’s disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.
A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs. Get them off!” Which problem is the patient experiencing?
a. Aphasia
b. Dystonia
c. Tactile hallucinations
d. Mnemonic disturbance
ANS: C
The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response?
a. “No bugs are on your legs. You are having hallucinations.”
b. “I will have someone stay here and brush off the bugs for you.”
c. “Try to relax. The crawling sensation will go away sooner if you can relax.”
d. “I don’t see any bugs, but I can tell you are frightened. I will stay with you.”
ANS: D
When hallucinations are present, the nurse should acknowledge the patient’s feelings and state the nurse’s perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient’s perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Risk for injury related to altered cerebral function, fluctuating levels of
consciousness, disturbed orientation, and misperception of the environment
b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by
confusion and inability to perform personal hygiene tasks
c. Disturbed thought processes related to medication intoxication, as evidenced by
confusion, disorientation, and hallucinations
d. Fear related to sensory perceptual alterations as evidenced by visual and tactile
hallucinations
ANS: A
The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient’s sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
a. Distraction using sensory stimulation
b. Careful observation and supervision
c. Avoidance of physical contact
d. Activation of the bed alarm
ANS: B
Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient’s safety.
A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient?
a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
b. Maintain soft lighting day and night. Keep a radio on low volume continuously.
c. Light the room brightly day and night. Awaken the patient hourly to assess mental
status.
d. Keep the patient by the nurse’s desk while awake. Provide rest periods in a room
with a television on.
ANS: A
A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
Which assessment finding would be likely for a patient experiencing a hallucination? The patient
a. looks at shadows on a wall and says, “I see scary faces.”
b. states, “I feel bugs crawling on my legs and biting me.”
c. reports telepathic messages from the television.
d. speaks in rhymes.
ANS: B
A hallucination is a false sensory without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.
