Health Assessment-Chapter 6-Substance Use

Which parameters would the nurse assess for when using the Alcohol Use Disorders Identification Test (AUDIT)? Select all that apply. 1 Adverse consequences 2 Withdrawal symptoms 3 Alcohol consumption 4 Tolerance 5 Drinking behavior

1 Adverse consequences 3 Alcohol consumption 5 Drinking behavior The AUDIT covers three domains: adverse consequences from alcohol, alcohol consumption, and drinking behavior. Withdrawal symptoms are assessed in the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised. Tolerance is assessed in the Tolerance, Worry, Eye-opener, Amnesia, and Kut down questionnaire. (pg. 89)

Which substance is the most used and abused psychoactive drug in the United States? 1 Alcohol 2 Cocaine 3 Morphine 4 Heroin

1 Alcohol Alcohol is the most used and abused psychoactive drug. More than half (56%) of Americans ages 18 and older report being current alcohol drinkers. Cocaine, morphine, and heroin are not the most used and abused. The prevalence of Americans ages 12 or older reporting the use of any of the illicit drugs listed above (cocaine, morphine, and heroin) is 10.1%.

Which screening instrument uses 4 questions to determine lifetime alcohol abuse and/or dependency? 1 Cut down, Annoyed, Guilty, Eye-opener (CAGE) 2 Alcohol Use Disorders Identification Test (AUDIT) 3 Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) 4 The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G)

1 Cut down, Annoyed, Guilty, Eye-opener (CAGE) The CAGE questionnaire uses 4 questions to help determine lifetime alcohol abuse and dependency in a patient; it does not, however, differentiate past problem drinking from active present drinking. The AUDIT is used to determine the effects of alcoholism in the patient and is a 10-question screening tool. The TWEAK questionnaire (5 questions) is used to assess alcohol abuse in women, especially those who are pregnant. The SMAST-G questionnaire is especially framed to assess alcohol abuse in older patients and has 10 yes/no questions.

Which findings alert the nurse to possible abuse in a patient? Select all that apply. 1 Explanations that don't match the injury 2 Inability to keep the story straight 3 Frequently seeking care for suspicious injuries 4 One bruise on the lower leg 5 A hip fracture from a fall

1 Explanations that don't match the injury 2 Inability to keep the story straight 3 Frequently seeking care for suspicious injuries Explanations that don't match the injury, inability to keep the story straight, and frequently seeking care for suspicious injuries are all cues to possible abuse. One bruise on the lower leg is not an indication of abuse. Multiple bruises in various stages of healing are indicative of abuse. A hip fracture from a fall is not a sign of abuse, but multiple fractures in various stages of healing are indicative of abuse. (pg. 102)

A patient has been consuming 3 alcoholic drinks daily for the past 6 weeks. Which finding in the laboratory report would be consistent with the patient's history? 1 Increased level of mean corpuscular volume 2 Increased level of gamma glutamyl transferase 3 Decreased level of carbohydrate deficient transferrin 4 Decreased level of serum aspartate aminotransferase

1 Increased level of mean corpuscular volume Heavy alcohol drinking for 4 to 8 weeks increases the mean corpuscular volume level. Chronic alcohol drinking of more than 4 drinks per day for 4 to 8 weeks elevates gamma glutamyl transferase (GGT) levels. This patient, however, consumes 3 drinks per day, and may not have an increased GGT. Elevation (not a decrease) of carbohydrate deficient transferrin occurs in a patient who drinks 50 to 80 g/day for 1 week. Chronic alcohol drinking for months raises serum aspartate aminotransferase levels; it does not lower them. (pg. 93)

Which clinical signs would the nurse observe in a patient who stops taking opioids abruptly? Select all that apply. 1 Lacrimation 2 Tachycardia 3 Hypersomnia 4 Pinpoint pupils 5 Decreased blood pressure

1 Lacrimation 2 Tachycardia Opioid withdrawal causes lacrimation and tachycardia. Lacrimation is excessive secretion of tears. Abrupt cessation of opioid consumption causes central nervous system stimulation, which may lead to tachycardia. Opioid withdrawal may cause insomnia; hypersomnia occurs as a result of amphetamine withdrawal. Pinpoint pupils and decreased blood pressure are characteristics of opiate intoxication, not withdrawal. Dilation of pupils and increased blood pressure occur during opiate withdrawal.

Which factors place older adults at a higher risk of developing complications related to alcohol abuse when compared with their younger counterparts? Select all that apply. 1 Less muscle mass 2 Impaired kidney function 3 Potential drug interactions 4 Elevated body water 5 Increased hepatic activity

1 Less muscle mass 2 Impaired kidney function 3 Potential drug interactions Less muscle mass, impaired kidney function, and potential drug interactions are factors that place older adult at higher risks of developing complication related to alcohol abuse when compared with their younger counterparts. Aging people lose muscle mass; less tissue to which the alcohol can be distributed means an increased alcohol concentration in the blood. As a result of aging, older adults tend to have impaired kidney functioning, which increases the bioavailability of alcohol. Older adults may be on several medications, which may interact adversely with alcohol. Body water is decreased (not elevated) in the older adult. Older adults have reduced hepatic activity, allowing the alcohol to be in the body for longer time periods.

Elevated levels of gamma glutamyl transferase (GGT) in a patient would alert the nurse to which possible conditions? Select all that apply. 1 Nonalcoholic liver disease 2 Alcohol relapse 3 Alcohol abstinence 4 Chronic alcohol drinking 5 Occasional alcohol drinking

1 Nonalcoholic liver disease 2 Alcohol relapse 4 Chronic alcohol drinking Nonalcoholic liver disease, alcohol relapse, and chronic alcohol drinking can all increase GGT levels. Nonalcoholic liver disease can increase GGT levels in the absence of alcohol. A sudden elevated GGT after normal GGT levels may indicate alcohol relapse in patients undergoing therapy. Chronic alcohol drinking damages the liver; therefore GGT levels increase. Alcohol abstinence would not cause the GGT to elevate. Occasional alcohol drinking does not elevate GGT levels.

Which drug would the nurse ask the patient about using when the patient exhibits piloerection, runny nose, and sweating? 1 Opiate 2 Alcohol 3 Amphetamine 4 Benzodiazepine

1 Opiate Piloerection, runny nose, and sweating are the symptoms observed when an opiate abuser withdraws from drug use. These symptoms occur when the central nervous system tries to regain its normal functions. Withdrawal symptoms of alcohol abuse include coarse tremor of the hands, tongue, and eyelids, and autonomic hyperactivity. Dysphoric mood, fatigue, insomnia, hypersomnia, and psychomotor agitation are signs associated with amphetamine withdrawal. Withdrawal symptoms of benzodiazepines include autonomic hyperactivity, orthostatic hypotension, and coarse tremors of the hands, tongue, and eyelids. (pg. 96)

Which nursing action would require written consent from an alert, adult patient who was abused by a partner? 1 Taking a digital photograph 2 Documenting statements made by the patient 3 Reporting previous abuses to the primary provider 4 Using partial direct quotations when charting

1 Taking a digital photograph Prior written consent to take digital photographs should be obtained from all cognitively intact, competent adults. Documentation of statements given by the patient and previous history of assaults do not require written consent because they are part of obtaining an accurate history and relaying pertinent information to other health care team members. Other aspects of the abuse history, including reports of past abusive incidents, can be paraphrased with the use of partial direct quotations. Written consent is not needed for this type of documentation. (pg. 101)

The nurse asks how often the patient consumes five or more drinks in any one occasion. Which response made by the patient is consistent with a score of 3 on the Alcohol Use Disorders Identification Test (AUDIT)? 1 "On a daily basis." 2 "About once a week." 3 "Only about once a month." 4 "Less than once a month."

2 "About once a week." The nurse would give a score of 3 if the patient states that he or she consumes five or more drinks weekly. The AUDIT includes 10 questions that determine the extent of alcohol problems and dependence disorders. A score of 4 indicates the patient consumes five or more drinks daily or almost daily. If the patient consumes five or more drinks monthly, the nurse would give a score of 2. A score of 1 indicates that the patient consumes five or more drinks on one occasion less than once in a month. (pg. 90)

Which statement made by the male patient alerts the nurse to the possibility of "at-risk" drinking? 1 "I only drink a total of 2 mixed drinks on the weekends." 2 "I drink 15 bottles of beer a week, usually with friends." 3 "I have a glass of wine every night with supper." 4 "I usually have 4 drinks on Friday and 4 on Saturday."

2 "I drink 15 bottles of beer a week, usually with friends." The male patient who drinks 15 bottles of beer a week is considered "at-risk" drinking. For a male patient, 15 or more drinks/week indicates "at-risk" drinking. For men, drinking 2 mixed drinks on the weekends is classified as low-to-moderate drinking patterns. One glass of wine every day indicates a low-to-moderate drinking pattern. A female patient who drinks 4 drinks on Friday and 4 drinks on Saturday indicates an "at-risk" drinker; however, a male patient would need to drink 5 or more drinks a day to be considered "at-risk" drinking. (pg. 89)

Which medical condition is a major cause of liver cirrhosis? 1 Tuberculosis 2 Alcohol abuse 3 Cardiomyopathy 4 Illicit drug use

2 Alcohol abuse Alcoholism is a major cause of liver cirrhosis. Although tuberculosis is associated with heavy drinking, it is not a major cause of liver cirrhosis. Although heavy daily drinking (>5 drinks per day) increases the risk of cardiomyopathy and heart failure, cardiomyopathy does not cause liver cirrhosis. Illicit drug use does not cause liver cirrhosis, but may affect the cardiovascular system, respiratory system, and brain. (pg. 85)

Which illicit drug is most commonly used in the United States? 1 Meperidine 2 Cannabis 3 Methamphetamine 4 Cocaine

2 Cannabis Cannabis (marijuana) use is the most common, used by almost 80% of drug users. Meperidine is a pain medication that is used but not as often as marijuana. Methamphetamine is a category of illicit drug use but is not used as often as cannabis. Although cocaine is a category of illicit drug use, its use is not as common as that of marijuana.

Which type of drinker would have increased levels of serum aspartate aminotransferase (AST)? 1 Abstinent 2 Chronic 3 Moderate 4 Occasional

2 Chronic Chronic drinking for months increases AST levels, an enzyme found in the liver. Chronic drinking causes inflammation of the liver, resulting in increased levels of AST. Abstinent or no drinking would not increase AST levels. Moderate drinking refers to female and male patients who drink less than 1 or 2 drinks per day, respectively; this has no immediate detrimental effect on the liver. Occasional alcohol drinking does not have any effect on levels of AST. (pg. 93)

Which assessment finding would indicate the patient has a substance abuse problem? 1 Develops withdrawal symptoms 2 Has an inability to stop using 3 Has absence of drug-related legal problems 4 Develops delirium tremens

2 Has an inability to stop using Substance abuse presents with an inability to stop using the substance. If the patient develops withdrawal symptoms, drug dependency has developed, not drug abuse. A patient with drug abuse has substance-related legal problems. Delirium tremens are a severe form of alcohol withdrawal, indicating a physical dependency on the drug, not drug abuse. (pg. 94)

Which examples are categories of illicit drug use? Select all that apply. 1 Antihypertensives 2 Inhalants 3 Beta-blockers 4 Hallucinogens 5 Marijuana

2 Inhalants 4 Hallucinogens 5 Marijuana Three of the 7 categories of illicit drug use include: inhalants, hallucinogens, and marijuana. Antihypertensives and beta-blockers are cardiovascular drugs that are not examples of illicit drug use.

Which parameters would the nurse assess for when using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)? Select all that apply. 1 Constipation 2 Tremor 3 Headache 4 Altered taste 5 Visual disturbances

2 Tremor 3 Headache 5 Visual disturbances Tremor, headache, and visual disturbances are assessed by the nurse. Ten parameters are assessed when using the CIWA-Ar. Nausea and vomiting, not constipation, are assessed. Tactile disturbances and auditory disturbances (not altered taste) are also assessed.

The patient answers yes to the questions pertaining to Tolerance and Eye-opener, but answers no for questions pertaining to Worry, Amnesia, and Kut down. What is the patient's total score when using the Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire? Record your answer using a whole number. __________

3 Because this patient answered yes for only the questions pertaining to Tolerance and Eye-opener, it indicates that the patient has a score of 3 (2+1) on the TWEAK questionnaire. The TWEAK questionnaire is used to assess alcohol dependency in pregnant women, and the scoring is based on the patient's responses to each question. The test gives 2 points each for Tolerance and Worry and 1 point each for Eye-opener, Amnesia, and Kut down questions. (pg. 91)

Which finding indicates a normal value for the breath alcohol analysis test? 1 0.08 2 0.10 3 0.00 4 0.12

3 0.00 Normal value for the breath alcohol analysis test is 0.00. A level of 0.08 is legal intoxication in most states. Levels of 0.10 and 0.12 indicate elevated levels of alcohol in the blood.

Which approximate number of standard drinks would be present in a 22-oz bottle of a malt liquor? 1 1.5 2 2 3 2.5 4 4.5

3 2.5 A 22-oz bottle of malt liquor contains 2.5 standard drinks. A standard drink is defined as one that contains about 14 grams of pure alcohol. A 12-oz bottle of malt liquor contains 1.5 standard drinks. A 16-oz bottle of malt liquor contains 2 standard drinks. A 40-oz bottle of malt liquor contains 4.5 standard drinks.

To determine the development of tolerance when using the Tolerance, Worry, Eye-opener, Amnesia, Kut down (TWEAK) questionnaire, which minimum amount of drinks would the patient consume? 1 2 2 3 3 4 4 8

3 3 The minimum number of drinks is 3. When using the TWEAK questionnaire, taking three or more drinks to feel high equals tolerance. Two is not enough drinks to establish tolerance. Although 4 would indicate tolerance, it is not the minimum amount. For women, 8 or more drinks/week indicates heavy or at-risk drinking, not tolerance. (pg. 91)

Which score on the Alcohol Use Disorders Identification Test (AUDIT) would alert the nurse to hazardous alcohol consumption in a 65-year-old patient? 1 1 2 2 3 4

3 4 A cut score of 4 or greater for those older than 60 years indicates hazardous alcohol consumption when using the AUDIT. One (1) is too low of a score to indicate hazardous alcohol consumption. A cut score of 2 or greater indicates possible alcohol abuse when using the Cut down, Annoyed, Guilty, Eye-opener (CAGE) test or the Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) test. A cut point of 3 or greater indicates heavy or at-risk drinking when using AUDIT-C. (pg. 89)

Which screening test would the nurse administer to a female patient with liver cirrhosis in an intensive care unit (ICU)? 1 Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire 2 Alcohol Use Disorders Identification Test (AUDIT) 3 Alcohol Use Disorders Identification Test-C (AUDIT-C) 4 The Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)

3 Alcohol Use Disorders Identification Test-C (AUDIT-C) The AUDIT-C is the most desirable tool for assessing alcohol abuse in a patient with a critical condition such as liver cirrhosis. The AUDIT-C is useful in acute and critical care units because it is a short assessment form with only three questions. The CAGE questionnaire helps determine lifetime alcohol abuse. It includes four straightforward questions, but it is less effective in women and among minority groups. The AUDIT is helpful in identifying problem drinking and people who need a more thorough assessment and is more useful in the emergency department and for trauma patients. The SMAST-G is used for assessing geriatric patients who drink alcohol on a regular basis; it is not specific for critically ill patients.

Which medical condition occurs when the patient drinks more than 5 drinks/day? 1 Schizophrenia 2 Cholecystitis 3 Cardiomyopathy 4 Brain cancer

3 Cardiomyopathy Heavy daily drinking (>5 drinks/day) increases the risk for cardiomyopathy and heart failure. Schizophrenia is not associated with heavy daily drinking, but depression and anxiety can occur. Liver cirrhosis, not cholecystitis, is associated with alcoholism. Breast, oral, esophageal, liver, and colorectal cancers (but not brain) are associated with alcohol intake. (pg. 85)

A patient with alcohol abuse presents with delirium tremens exhibiting irregular tremors and tachycardia. Which additional finding would the nurse monitor for? 1 Reddened eyes 2 Hypervigilance 3 Fever 4 Yawning

3 Fever Fever occurs during delirium tremens. Cannabis abuse/intoxication does not cause delirium tremens but can cause reddened eyes. Hypervigilance may occur during cocaine abuse/intoxication. Yawning occurs during opiate withdrawal, not during delirium tremens. (pg. 94)

Which area would the nurse address to determine run-ins related to a patient's use of alcohol? 1 Work obligations 2 Bodily harm 3 Legal problems 4 Family troubles

3 Legal problems The nurse would address legal problems related to alcohol to determine run-ins. Run-ins relate to problems with the law, such as arrests or other legal issues. "Work obligations" refers to role failure, not run-ins. Risk for bodily harm relates to issues such as drinking and driving or drinking while swimming or operating machinery. Relationship trouble refers to difficulties with family and/or friends, whereas run-ins occur with the law. (pg. 91)

Which direct serum biomarker would help detect moderate alcohol intake in a patient? 1 Mean corpuscular volume 2 Aspartate aminotransferase 3 Phosphatidylethanol 4 Gamma glutamyl transferase

3 Phosphatidylethanol Phosphatidylethanol is the only biomarker that can detect moderate alcohol intake. It is a phospholipid produced only in the presence of alcohol. Mean corpuscular volume is not sensitive enough to use as the only biomarker for problem drinking, and it detects heavy alcohol drinking. Aspartate aminotransferase is an enzyme found in high concentrations in the heart and liver, and chronic drinking for months increases the level. Occasional alcohol drinking does not raise gamma glutamyl transferase (GGT), but chronic heavy drinking does. Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol.

Which kind of injury is caused by friction? 1 Cut 2 Bruise 3 Rug burn 4 Laceration

3 Rug burn The injuries that occur because of friction are known as rug burns. A rug burn is characterized by a scraped area of skin. A cut is caused by a sharp object. A bruise is the reddening and purpling of the skin that may occur because of the impact of a blow. A laceration is a wound that occurs because of splitting or tearing of the skin surface caused by blunt force trauma. (pg. 106)

Which score on the Alcohol Use Disorders Identification Test (AUDIT) would alert the nurse to a possibility of hazardous alcohol consumption in an adolescent? 1 1 2 2 3 3 4 4

4 4 A cut point of >4 points for adolescents, women, and those older than 60 years indicates hazardous alcohol consumption. One, two, or three points are too low to alert the nurse to the possibility of hazardous alcohol consumption. (pg. 89)

Which type of abuse involves belittling and threatening? 1 Neglect 2 Sexual 3 Physical 4 Emotional

4 Emotional Belittling and threatening are examples of emotional abuse. Neglect includes lack of supervision and failure to provide the basic physical, emotional, and medical needs. Sexual abuse includes rape, sodomy, and penetration. Physical abuse includes biting, pushing, shaking, kicking, punching, and beating. Physical abuse may result in injuries.

The patient who has endured forced sex presents with chronic pelvic pain. Which additional condition would the nurse monitor for? 1 Asthma 2 Upper respiratory infections 3 Diabetes mellitus 4 Urinary tract infections

4 Urinary tract infections Forced sex contributes to a host of reproductive health problems, including chronic pelvic pain and urinary tract infections. Asthma, upper respiratory infections, and diabetes mellitus are not a result of forced sex. Each of these conditions has an etiology not associated with abusive sex.

Which condition is associated with sympathetic system stimulation because of alcohol intake? 1 Hypoactivity 2 Hypotension 3 Vasodilation 4 Vasoconstriction

4 Vasoconstriction Intake of alcohol activates the sympathetic nervous system, which constricts blood vessels (vasoconstriction). This, in turn, causes hypertension in the patient. Hypoactivity, hypotension, and vasodilatation are caused by inhibition of the sympathetic nervous system. (pg. 85)