Flashcards in Chapter 22 Deck (35):
1. A patient diagnosed with alcoholism 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.”
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.
2. 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/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 148/94 mm Hg and 96 beats/min
What is the nurse’s priority action?
a. Force fluids.
b. Consult the health care provider.
c. Obtain a clean-catch urine sample.
d. Place the patient in a vest-type restraint.
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. 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.
3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority?
a. Cardiovascular c. Neurologic
b. Respiratory d. Hepatic
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. See relationship to audience response question.
4. 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/min. 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.
Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.
5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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
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.
6. A hospitalized patient diagnosed with an alcohol abuse 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 (Dilaudid).
b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).
c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril).
d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).
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.
7. A hospitalized patient diagnosed with an alcohol abuse 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 c. Keep the room dimly lit
b. One-on-one supervision d. Force fluids
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.
8. A patient diagnosed with an alcohol abuse 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.”
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.
9. A patient asks for information about Alcoholics Anonymous. Select the nurse’s best response. “Alcoholics Anonymous 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.”
Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.
10. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior 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.
A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. 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.
11. A patient admitted to an alcoholism 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 c. Introjection
b. Projection d. Rationalization
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.
12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?
a. Bromocriptine (Parlodel)
b. Methadone (Dolophine)
c. Disulfiram (Antabuse)
d. Naltrexone (ReVia)
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.
13. 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.”
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.
14. 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.
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.
15. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction.
a. Empathetic, supportive c. Cool, distant
b. Skeptical, guarded d. Confrontational
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.
16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose?
a. Simple and safe
b. Active and bright
c. Stimulating and colorful
d. Confrontational and challenging
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.”
17. 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.
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.
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:
a. codependence. c. role reversal.
b. assertiveness. d. homeostasis.
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. See relationship to audience response question.
19. In the emergency department, a patient’s vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic 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/min, and respirations at or above 12 breaths/min.
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.
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.
20. 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.”
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.
21. Which goal for treatment of alcoholism should the nurse address first?
a. Learn about addiction and recovery.
b. Develop alternate coping strategies.
c. Develop a peer support system.
d. Achieve physiologic stability.
The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.
22. A patient 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
Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.
23. 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.
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.
24. 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.
The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)
25. 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. c. substance addiction.
b. substance abuse. d. substance intoxication.
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.
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
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. (Educators may alter this question to multiple answers if desired.)
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.” Vital signs are slightly elevated. The nurse should suspect:
a. a schizophrenic episode. c. opium intoxication.
b. hallucinogen ingestion. d. cocaine overdose.
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.
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 – National Research Council (IOM)
c. National Council of State Boards of Nursing (NCSBN)
d. American Society of Addictions Medicine
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.
29. 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 c. Barbiturates
b. Heroin d. Amphetamines
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.
30. 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.
The key refers to 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.
31. 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.
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.
1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) 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.
2. 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.
3. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply)
a. administration of naloxone (Narcan).
b. vitamin B12 and folate supplements.
c. restoring nutritional integrity.
d. management of heart rate.
e. environmental safety.
ANS: D, E
Care of patients who have taken bath salts is similar to those who have used other stimulants. Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.