Addiction/IPV Flashcards
(27 cards)
What is the priority nursing action for a client in alcohol withdrawal?
Administer prescribed lorazepam
Benzodiazepines are the first-line treatment for alcohol withdrawal to prevent seizures, delirium tremens, and anxiety.
Which clinical signs support suspicion of opioid intoxication? (Select all that apply)
- Miosis (pinpoint pupils)
- Respiratory depression
- Bradypnea
Opioid intoxication typically presents with pinpoint pupils, respiratory depression, and bradypnea.
Which laboratory value is most indicative of chronic alcohol use?
Elevated ALT/AST
Chronic alcohol use can cause liver enzyme elevation, especially AST > ALT ratio.
What essential teaching point should be made to a client prescribed naltrexone?
You must avoid all opioid medications while on this drug
Naltrexone is an opioid receptor antagonist, and opioids taken while on this drug can lead to precipitated withdrawal.
What is the priority nursing diagnosis for a client experiencing severe alcohol withdrawal?
Risk for injury
The primary concern during severe withdrawal is seizure activity or falls due to confusion.
What should a nurse do first when a pregnant client presents with bruising?
Interview the client alone using open-ended questions
Private assessment in a safe space is essential in suspected IPV cases.
Which statements indicate a high risk for lethality in an IPV situation? (Select all that apply)
- He said he’d kill me if I left.
- He has a gun and has threatened to use it.
- I think I’m safer if I just stay.
Death threats, access to weapons, and fear of leaving are strong indicators of escalating violence.
Which documentation practices are correct for a client who is a victim of IPV? (Select all that apply)
- Client states her boyfriend hit her with a belt.
- Noted 3 linear bruises on posterior thighs.
- Client denies injury but cries throughout interview.
- Photographs taken with consent.
Objective documentation and direct quotes are appropriate, avoiding subjective statements.
What is the priority nursing intervention for a woman with a history of IPV who wants to leave her abuser?
Help the patient create a safety plan
Empowering the client to create a personalized safety plan is the nurse’s role.
Which signs may indicate abuse in a child during a pediatric assessment? (Select all that apply)
- Spiral fractures inconsistent with developmental stage
- Multiple bruises in different stages of healing
- Delay in seeking treatment for injuries
- Burn patterns consistent with glove or stocking distribution
These findings are red flags for abuse.
Which signs are most characteristic of alcohol withdrawal? (Select all that apply)
- Hand tremors
- Nausea and vomiting
- Hallucinations
Classic signs include tremors, GI upset, hallucinations, anxiety, and increased HR/BP.
Which symptom during alcohol withdrawal requires immediate intervention?
Seizure activity
Seizures may precede delirium tremens, a life-threatening withdrawal complication.
Which lab values would be expected in a client with chronic alcohol use disorder? (Select all that apply)
- Elevated AST/ALT
- Increased GGT
- Elevated ammonia
- Decreased albumin
Alcohol-related liver disease often results in elevated liver enzymes and low albumin.
Which diagnostic finding most supports opioid overdose suspicion?
ABG showing respiratory acidosis
Respiratory depression leads to CO₂ retention and respiratory acidosis.
What medication is used as an emergency opioid antagonist?
Naloxone
Naloxone reverses opioid overdose by displacing opioids from receptor sites.
What teaching is appropriate for a client prescribed buprenorphine/naloxone?
This will prevent opioid cravings and withdrawal symptoms
Suboxone is used for maintenance therapy.
Which medication produces an aversive reaction with alcohol?
Disulfiram
Disulfiram inhibits aldehyde dehydrogenase, causing adverse reactions if alcohol is consumed.
What is the nurse’s priority action when a client enters with suspected opioid withdrawal?
Obtain urine drug screen
Objective confirmation of substance is essential for accurate diagnosis.
Which interventions are appropriate during acute alcohol withdrawal? (Select all that apply)
- Administer benzodiazepines per CIWA protocol
- Reduce environmental stimuli
- Provide thiamine and multivitamins
- Monitor for hallucinations and seizures
Key priorities include safety and preventing Wernicke’s encephalopathy.
Which findings suggestive of intimate partner violence? (Select all that apply)
- Client avoids eye contact and defers questions to partner
- Injuries inconsistent with the stated cause
- Client has repeat visits for vague pain complaints
- Client has a history of emergency contraception use
Common red flags include inconsistencies and controlling partner dynamics.
What is the priority assessment question for a pregnant woman with bruising?
Do you feel safe in your current relationship?
This encourages disclosure while maintaining therapeutic rapport.
Which tools are commonly used to screen for IPV? (Select all that apply)
- HITS Questionnaire
- Danger Assessment Tool
- RADAR mnemonic
HITS and the Danger Assessment assess abuse risk.
Which lab tests should be prioritized in a child suspected of abuse? (Select all that apply)
- Coagulation studies
- Liver function tests
- Skeletal survey
- Head CT
These help distinguish between abuse and medical conditions.
What should the nurse monitor for a client prescribed paroxetine for IPV-related PTSD?
Increased suicidal thoughts
SSRIs like paroxetine carry a black box warning for increased suicide risk.
