Alcohol Abuse (LPN)

A pregnant woman states, "It's a myth that a glass of wine a day will harm the baby. People in other countries do it often, and their babies are fine." Which response by the nurse reflects evidence-based practice? A) "it is irresponsible to drink any amount of alcohol while you're pregnant; it will cause fetal abnormalities in all cases." B) "Women who drink one drink per week are at risk for delivering a stillborn baby. It's important to protect the well-being of your fetus at all times." C) "It's best not to drink while you're pregnant, but it will be fine when you're breastfeeding." D) "Alcohol use is linked to an increased risk of miscarriage and increased rates of prematurity and abruption placentae."

"Alcohol use is linked to an increased risk of miscarriage and increased rates of prematurity and abruption placentae." Rationale: Alcohol is the most common teratogen in pregnancy. Alcohol use is associated with spontaneous abortion​ (miscarriage), increased rates of​ prematurity, and abruptio placentae​ (separation of placenta from the uterine​ wall). Women who drink during breastfeeding pass alcohol on to the​ baby, which can cause adverse outcomes. Fetal alcohol spectrum disorders​ (FASDs) are a risk but are typically associated with prolonged exposure to alcohol in utero. Women who consume five or more drinks per week while pregnant are three times more likely to deliver a stillborn baby compared with those who had less than one drink per week.

On assessment, the nurs notes spider angiomata to the client's face an abdomen, jaundice, and ascites of a client with cirrhosis. The client tells the nurse that he plans to stop drinking to reverse his cirrhosis. Which is the most appropriate response by the nurse? A) "Cirrhosis cannot be reversed, but abstaining from alcohol can prevent further damage." B) "Abdominocentesis will help to reduce the ascites." C) "The liver has the potential to regenerate if alcohol exposure is limited." D) "Avoid medications such as acetaminophen to improve your liver function."

A) "Cirrhosis cannot be reversed but abstaining from alcohol can prevent further damage." Rationale: The client is demonstrating severe signs of liver cirrhosis. The goal is to prevent further damage to the liver. Symptom management is​ possible, but it will not cure the cirrhosis. It is important for the nurse to be clear that the cirrhosis will not resolve but that abstaining from alcohol may prevent further liver damage and its associated symptoms. Abdominocentesis will provide symptom management for ascites but is not a cure. Avoiding acetaminophen is recommended but it will not reverse the cirrhosis. The liver will not regenerate to reverse cirrhosis.

The nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife make which statement? A) "I no longer feel that I deserve the beatings my husband inflicts on me." B) "My attendance at the meetings has helped me to see that I provoke my husband's violence." C) "I enjoy attending the meetings because they get me out of the house and away from my husband." D) "I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics." (Saunders)

A) "I no longer feel that I deserve the eatings my husband inflicts on me." Correct answer b/c: it exemplifies an understanding that the alcoholic partner is responsible for his behavior and can't be allowed to blame family members for loss of control.

A college student attends a seminar on alcohol abuse. Which statement would alert the nurse that the student needs more education? A) "The children of alcoholics have a lower risk of becoming an alcoholic." B) " Native Americans are at higher risk of becoming alcoholic." C) "Married college graduates are less likely to become alcoholics." D) Childless people are more likely than parents to become alcoholics."

A) "The children of alcoholics have a lower risk of becoming an alcoholic." Rationale: Genetic and environmental factors put both Native Americans and children of alcoholics at greater risk for developing alcoholism. Married people, college graduates, and people with children are less likely to become alcoholics.

A hospitalized client with a history of alcohol abuse tells the nurse, "I'm leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the room. Which is the appropriate nursing action? A) Call the nursing supervisor B) Call security to block all exit areas C) Tell the client that she cannot return to this hospital again if she leaves now D) Restrain the client until the primary HCP can be reached (Saunders)

A) Call the nursing supervisor Rationale: The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she can't leave the hospital. Notifying the nurse supervisor is the correct option. The client should sign an AMA document before leaving

The nurse notes that a client's score on the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) has continued to increase. Which assessment would provide the nurse more information about the client's condition? A) Drawing blood alcohol level (BAL) and obtaining vital signs B) Assessing for delusions or hallucinations C) Assessing for tremors and vomiting D) Ensuring that the CIWA-Ar score has been administered correctly

A) Drawing BAL and obtaining vital signs Rationale: It is important to assess blood alcohol levels routinely and to look for escalating signs of withdrawal using an instrument such as​ CIWA-Ar. BAL when paired with vital signs will provide information about the need for prn medications to prevent delirium tremens​ (DTs) and other severe complications. BAL and vital signs will help to determine if medication therapy is required for withdrawal. Assessment for delusions or​ hallucinations, tremors, and vomiting has already been completed as part of the​ CIWA-Ar tool. The scenario has indicated that the​ CIWA-Ar score is increasing. It is important to use the data that has been given to the nurse because there is no indication in the question that it has been administered incorrectly.

The nurse is helping students form a peer-support team to implement a harm-reduction program for alcohol use at a high school. Which topic is of the highest priority in this population? A) Risk of sexual assault related to alcohol use B) Impact of social media and underage drinking C) Role of alcohol in increasing hyperactivity and aggression in adolescents D) Links to anxiety and panic associated with alcohol use

A) Risk of sexual assault related to alcohol use Rationale: These answers are all correct because they outline the risk of alcohol use in adolescent populations.​ However, the question focuses on identifying the area of highest priority. In this​ case, the highest priority is safety. Educating adolescents on the risk of sexual assault with binge drinking is essential. Alcohol may also cause emotional disturbances such as anxiety and panic and hyperactivity and aggression. Adolescents may also be pressured by social media to engage in underage drinking. These remain important areas for​ education, but safety from sexual assault is the highest priority.

A 20yo woman discloses to the nurse that she has been drinking six to eight drinks a night after breaking up with her partner 2 weeks ago. She states that it is only temporary and that she will not become an alcoholic. Which is a cause of concern based on the nurse's knowledge of alcohol abuse in women? A) Women develop alcohol abuse and dependence in less time than men do. B) Women have a higher first-pass metabolism of alcohol in the stomach and upper small intestine C) Women who are dependent on alcohol or consume heavier amounts are at a greater risk for hypotension D) Women who go through breakups are more likely to be pregnant.

A) Women develop alcohol abuse and dependence in less than men do Rationale: Women develop alcohol abuse and dependence in less time than do​ men; this is called telescoping. Women may also develop liver damage at lower levels of consumption over shorter periods of time. It is important that the nurse teaches the client about this phenomenon and helps her to find better coping mechanisms for her grief. Women who are dependent on alcohol or consume heavier amounts are at risk for hypertension. There is no correlation between the end of a relationship and risk of pregnancy with women. Women who drink the same amount of alcohol as do men will have higher blood alcohol concentrations because women have more body fat and a lower volume of body water to dilute alcohol.

*Shit question alert* A client admitted 3 days ago is now experiencing alcohol withdrawal delirium. Which nursing intervention should be implemented to promote safety for the client? SATA A) Assessing the client's level of orientation frequently B) Explaining all interventions before approaching the client C) Using simple step-by-step instructions with the client D) Encouraging the client to verbalize fears E) Teaching the client healthy coping mechanisms

A, B, C Rationale: Assessing the​ client's level of orientation​ frequently, explaining all interventions before approaching the​ client, and using simple​ step-by-step instructions with the client are all examples of promoting safety for the client during alcohol withdrawal. Teaching the client healthy coping mechanisms and encouraging the client to verbalize fears are examples of promoting healthy coping skills.

The nurse is evaluating a client's progress in recovering from acute alcohol withdrawal. Which finding should the nurse evaluate as positive? SATA A) The client stays away from old drinking buddies B) The client has adopted healthful eating habits C) The client regularly attends Alcoholics Anonymous (AA) meetings D) The client has returned to a full-time work schedule E) The client and spouse have moved into separate homes

A, B, C, D Rationale: Positive findings are the​ client's regular attendance at AA​ meetings, adoption of healthful eating​ habits, successful return to​ work, and avoidance of old drinking companions. Separating from the family is not a positive finding.

The nurse notes that client's blood alcohol level (BAL) is 0.10%. Which symptom supports the client's current BAL? SATA A) Lack of coordination B) Frequent seizures C) Difficulty with speech D) Clumsy behavior E) Inability to remain upright

A, C, D Rationale: Ataxia​ (lack of​ coordination), clumsy​ behavior, and dysarthria​ (difficulty with​ speech) are all symptoms associated with BALs of​ 0.10%. Inability to remain upright is associated with BALs of​ 0.20% to​ 0.25%. Seizures are associated with withdrawal symptoms and are not correlated with a​ client's BAL.

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? SATA A) Monitor vital signs B) Maintain an NPO status C) Provide a safe environment D) Address hallucinations therapeutically E) Provide stimulation in the environment F) Provide reality orientation as appropriate (Saunders)

A, C, D, F

The nursing assessment findings for a client with alcohol abuse include a recent fall at home, decreased appetite, report of blurred vision, and a denial that alcohol has negative effects on the ody. Which is an appropriate goal for this client for this client at this time? SATA A) The client will maintain adequate nutrition B) The client will participate in a support group C) The client will remain sober D) The client will remain free of injury E) The client will verbalize the negative effects of alcohol on the body

A, D, E Rationale: Based on the assessment​ findings, appropriate goals include that the client will remain free of​ injury, will verbalize the negative effects of alcohol on the​ body, and will maintain adequate nutrition. While the​ client's remaining sober and participating in a support group are appropriate goals in general for a client with alcohol​ abuse, they are not appropriate at this time based on the assessment findings.

The nurse is conducting a health history and wants to determine the client's level of alcohol use. What question from the nurse will provide the greates amount of information? A) "Are you a heavy drinker?" B) "How many alcoholic beverages do you drink each day?" C) "Is alcohol use a concern for you?" D) "Drinking doesn't cause any problems for you, does it?"

B) "How many alcoholic beverages do you drink each day?" Rationale: Open-ended questions will elicit the greatest amount of information about the client's alcohol use. Asking closed questions that can be answered with a "yes" or "no" will limit the information obtained by the nurse.

A client tells the nurse about their increasing anxiety and use of alcohol to help reduce their anxiety symptoms. Which complementary health approach should the nurse suggest to better promote the client's health and reduce their use of alcohol? A) "Acupuncture has been proven to cure anxiety and alcoholism." B) "It would be helpful to use neuropathy and yoga as a substitute for drinking alcohol." C) "It is difficult to manage anxiety without the use of pharmacologic therapy." D) "It may be helpful to use and herbal supplement such as kava kava for your anxiety."

B) "It would be helpful to use neuropathy and yoga as a substitute for drinking alcohol." Rationale: The goal is to promote the​ client's health and to limit the use of alcohol for anxiety. Neurotherapy​ (biofeedback) and yoga may provide calming effects on the centers of the brain involved in anxiety and impulse control. Acupuncture has been used to reduce the cravings for a variety of​ substances, but this answer states that it cures anxiety and​ alcoholism, which is not true. Kava kava is an antianxiety herbal​ supplement, but it can cause liver damage. Anxiety can be managed with other approaches besides pharmacologic therapy.

A client of America Indian descent who states that he abstains from drinking alcohol because his father died from complications related to alcoholism is concerned that his children may be at risk. Which nursing statement is the most accurate in summarizing the genetic influences related to the potential for alcohol abuse in this population? A) "Ensuring that children do not drink at a young age will help decrease the risk of alcoholism in the future." B) "Research has shown that American Indians carry risk factors associated with drug sensitivity and tolerance." C) "Genetic influences related to alcohol dependency are linked to exposure to trauma." D) "Social determinants of health are the greatest genetic influence in the development of alcohol abuse."

B) "Research has shown that American Indians carry risk factors associated with drug sensitivity and tolerance." Rationale: American Indians experience alcoholism at higher rates than do other populations. Genetics is a contributing factor. It has been found that American Indians do not have the genes that alter​ alcohol-metabolizing enzymes, and they lack protective variants found in other groups. This genetic variance can lead to drug sensitivity and tolerance. The incorrect answers focus on​ environmental, rather than genetic factors. Environmental factors that may contribute include early onset​ drinking, trauma​ exposure, and environmental hardship.

The client who is a chronic alcohol abuser is being assessed by the nurse. Which problems are related to thiamin deficiency? A) Cardiovascular symptoms, such as decreased hemoglobin and hematocrit levels B) CNS symptoms, such as ataxia and peripheral neuropathy C) GI symptoms such as nausea and vomiting D) Respiratory symptoms, such as cough and sore throat

B) CNS symptoms such as ataxia and peripheral neuropathy Rationale: Wernicke's encephalopathy is a CNS disorder caused by acute thiamin deficiency in people who abuse alcohol. Other symptoms, besides ataxia and peripheral neuropathy, are acute confusion or delirium. Cardiovascular and gastrointestinal symptoms are associated with alcohol abuse; they are not caused by thiamin deficiency. Respiratory problems are not usually directly related to alcohol.

Which of the following signs and symptoms would least likely be observed in a client who is experiencing alcohol withdrawal syndrome? A) Anorexia B) Hypotension C) Visual hallucinations D) Hyperthermia

B) Hypotension Rationale: Signs and symptoms of alcohol withdrawal syndrome include anorexia, hallucinations, and hyperthermia. Hypotension is not associated with alcohol withdrawal syndrome, but hypertension is.

The nurse assesses a client with a history of alcoholism who is hospitalized with anorexia, dysphagia, odynophagia, and chest pressure after eating. Which nursing diagnosis is a priority for this client? A) Ineffective Coping B) Imbalanced Nutrition: Less than body requirements C) Disturbed Sensory Perception D) Disturbed Thought Processes

B) Imbalanced Nutrition: Less than Body Requirements Rationale: A client with anorexia and a history of alcoholism is at risk for a diagnosis of Imbalanced Nutrition: Less than Body Requirements. The client's symptoms of dysphagia, odynophagia, and chest pressure after eating further support this diagnosis. Ineffective Coping is a potential diagnosis associated with substance abuse, but it is not suggested by the symptoms given here. Disturbed Thought Processes and Disturbed Sensory Perception are diagnoses appropriate for clients who are experiencing delusions, hallucinations, and illusions associated with delirium tremens, but again, these diagnoses are not suggested by the symptoms listed here.

Which outcome is expected for the client who has been treated for alcohol abuse? SATA A) Absence of anxiety B) Ability to verbalize negative aspects of alcohol abuse C) Regular attendance at a self-help group D) Improved nutritional status E) Minimal alcohol use

B, C, D Rationale: Expected outcomes for the client who has been treated for alcohol abuse include improved nutritional​ status, ability to verbalize negative aspects of alcohol​ use, and regular attendance at a​ self-help group like Alcoholics Anonymous​ (AA). The client is expected to remain free of alcohol​ use, not keep it to a minimum. Anxiety is expected to be controlled at an acceptable and manageable​ level, not to be absent.

An 80yo client states he drinks a 6 pack of beer each night. When reviewing the client's daily medications, which should concern the nurse the most? SATA A) Antihypertensive B) Laxative C) Antidepressant D) Antihistamine E) Cough syrup

B, C, D, E Rationale: ​Rationale: Mixing prescription and​ over-the-counter medicines or herbal remedies with alcohol can be dangerous or even deadly for older​ adults, who routinely take medications for chronic health issues. The nurse reviewing the medications would be concerned about cough syrup and laxatives because some can contain alcohol and create an additive effect with the​ client's alcohol use. Alcohol combined with some antidepressants can cause respiratory depression. Cold and allergy medications containing antihistamines can cause​ drowsiness, and can cause problems when mixed with alcohol. Antihypertensives generally do not interact with alcohol.

A client presents to the ED with signs of alcohol withdrawal. Which statement would be consistent for the client to make 6 to 8 hours after their last drink? SATA A) "Where am I? Who are you? B) "My heart feels like it's going faster than normal." C) "I feel like I can't sit still, I don't want to stay in the bed." D) "Can you see the spiders crawling on the wall?" E) "Stop bothering me! You keep waking me up!"

B, C, E Rationale : Signs of alcohol withdrawal syndrome occurring 6 to 8 hours after the last drink include​ irritability, increased anxiety and​ tremor, and mild tachycardia. Clients may feel their heart rate has increased​ (mild tachycardia). They may be irritable and ask not to be touched or left​ alone, and they may display signs of anxiety such as not sitting still or staying in the bed. Later signs of alcohol withdrawal such as confusion to​ person, place, and time and hallucinations typically occur 2 to 3 days after the last drink.

A pregnant client tells the nurse that she and her husband are going to a 50th wedding anniversary party for her grandparents this weekend. The client asks the nurse if it will be okay for her to have a few glasses of wine at the party. Which response by the nurse is appropriate? A) "Drinking a few glasses of wine will not be a problem." B) "Consuming alcohol during pregnancy can cause the baby to be born without limbs." C) "Drinking any alcoholic beverages of any type during pregnancy puts your baby at risk for injury." D) "Wine is acceptable, but not hard liquor."

C) "Drinking any alcoholic beverages of any type during pregnancy puts your baby at risk for injury." Rationale: Drinking any alcohol, no matter what type and what quantity, during pregnancy increases the risk for accidents and damage to the infant. Women should be encouraged to drink no alcohol at all during pregnancy. Wine can put the mother and fetus at risk as much as hard liquor.

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement? A) "Why don't you tell your husband about this?" B) "This is not the best time to make this decision." C) "What do you find difficult about this situation?" D) "I agree with you. You should get out of this situation." (Saunders)

C) "What do you find difficult about this situation?" Rationale: The most helpful response is the one that encourages the client to problem solve

The nurse is completing health teaching for a client who has been prescribed an alcohol deterrent. Which food or medication should the nurse instruct the client to avoid while taking this medication therapy? A) NSAID B) Analgesics C) Cough syrup D) Grapefruit juice

C) Cough syrup Rationale: An alcohol deterrent is a form of aversion therapy that prevents the breakdown of​ alcohol, causing the symptoms of physical illness in an individual who consumes alcohol while taking the medication. Alcohol can be present in cough syrups and mouthwash. It is important to teach​ clients, so they do not suffer a reaction from ingesting these products. Grapefruit juice may interfere with the metabolism of​ medications, but it does not have an influence on an alcohol deterrent. Analgesics and nonsteroidal​ anti-inflammatories can be safely administered with this medication.

The nurse is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in: A) Abdominal cramps and diarrhea B) Drowsiness and decreased respiration C) Flushing, vomiting, and dizziness D) Increased pulse and BP

C) Flushing, vomiting, and dizziness Rationale: Disulfiram (Antabuse) prevents complete alcohol metabolism in the body. Therefore when alcohol is consumed, the client has a hypersensitivity reaction. Flushing, vomiting, and dizziness are associated with the incomplete breakdown of alcohol metabolites. Other choices are not associated with the use of disulfiram along with alcohol.

The nurse recommends that the family of a client with an alcohol disorder attend a support group. The purpose of these groups is to help family members understand the problem and to: A) Change the problem behaviors of the abuser B) Learn how to assist the abuser in getting help C) Maintain focus on changing their own behaviors D) Prevent substance problems in vulnerable family members

C) Maintain focus on changing their own behaviors Rationale: Family support groups, such as Al Anon and Alateen, emphasize the importance of changing one's own behavior rather than trying to change the behavior of the individual with a substance abuse problem. Trying to change the abuser's behavior or learning ways to find help for the abuser would be viewed as codependent behaviors, and thus would not be advocated by family support groups. Learning about substance abuse may help a vulnerable family member to avoid this problem; however, that is not the purpose of these groups.

The nurse is completing a health screening for alcohol abuse for clients in a primary care clinic. Which client should the nurse prioritize for immediate assessment based on the nurse's knowledge of risk factors for alcohol abuse? SATA A) A 24yo college student in graduate studies B) A 19yo client who has a 2 week old newborn at home C) A 32yo client living in a house without heat or water D) A 20yo client who recently experienced a sexual assault E) A 13yo girl who has started drinking at parties

C, D, E -Trauma exposure -Environmental hardship -Early Onset alcohol use Rationale: Clients with known trauma​ exposure, environmental hardships such as loss or lack of​ housing, and noted early onset use of alcohol should be screened as a priority for alcohol abuse.​ Less, not​ more, education after high school is associated with higher rates of alcohol abuse. Becoming a parent is associated with lower rates of alcohol abuse and is not a risk factor.

The nurse is evaluating a list of outcome goals for a client with alcoholism who is being discharged from a detoxification program. The list was written by a nursing student who is being mentored by the nurse. Which of the following outcomes are appropriate for this client? SATA A) Follow a 2000 calorie, high carb diet B) Sponsor a participant in AA meetings C) Obtain at least 6-8 hours of sleep per night D) Acknowledge the blame that family members must take for codependent behavior E) Enroll in the Employee Assistance Program (EAP) through the client's employer

C, E Rationale: Appropriate outcomes for a client who is being discharged from alcohol detoxification are to obtain at least 6-8 hours of sleep per night and to enroll in an Employee Assistance Program if one is offered through the client's employer. The client's calorie requirement should be individualized and may not be 2000 calories. New or returning AA members should be sponsored; they are not ready to sponsor another person. The client should accept responsibility for his or her behavior in the family unit instead of assigning blame for codependent behavior.

As compared to men, women are: A) less likely to begin regularly using alcohol at an early age B) Likely to wait a greater number of years before entering treatment for alcohol abuse C) Less susceptible to alcohol-related organ damage D) Likely to experience greater cognitive impairment from alcohol consumption

D) Likely to experience greater cognitive impairment from alcohol consumption Rationale: No gender difference has been noted for age at onset of regular alcohol use, but women typically use alcohol for fewer years than men before entering treatment. Compared with men, women experience greater cognitive impairment by alcohol and are more susceptible to alcohol-related organ damage.

Which medication is commonly used in treatment programs for heroin abusers to produce a non-eupohoric state and to replace heroin use? A) Diazepam B) Carbamazepine C) Clonidine D) Methadone

D) Methadone Rationale: Methadone maintenance programs are used to provide a heroin-depleted individual with a medically controlled dose of methadone to produce a non euphoric state that will prevent withdrawal symptoms. This method of treatment is advocated to help heroin abusers avoid criminal activities associated with obtaining heroin; it also prevents diseases associated with I.V. use of heroin. Diazepam and carbamazepine may be used for withdrawal from alcohol, barbiturates, and benzodiazepines. Clonidine can be used in acute withdrawal from heroin to avoid norepinephrine rebound when opiates are stopped

The nurse is providing care to a client with alcoholism. The client's physical examination reveals a BMI of 18. Which prescription does the nurse anticipate to manage the client's nutritional status? A) Sertaline B) Methadone C) Naloxone D) Multivitamin

D) Multivitamin Rationale: A client with alcohol dependence may suffer from numerous nutritional deficiencies, including deficiencies in thiamine, folic acid, vitamin A, magnesium, and zinc. A multivitamin may be prescribed to help with these deficiencies. Naloxone is used to manage an opiate overdose. Methadone is prescribed to manage heroin cravings. Sertraline is used to reduce anxiety and stabilize mood.

The nurse is developing the plan of care for a 65yo man admitted with alcohol abuse and withdrawal symptoms who denies drinking. The family tells the nurse that the client's drinking is impacting his daily life. Which primary goal should the nurse include in the plan of care? A) The client will achieve optimal nutritional status B) The client will participate in support groups such as AA after discharge C) The client will remain sober D) The client will admit that alcohol is controlling his life.

D) The client will admit that alcohol is controlling his life Rationale: Goals for client care depend on the​ client's needs. This client is denying a problem with alcohol. Even though the family has outlined that his alcohol abuse is impacting his daily​ activities, the nurse must first help the client in recognizing that alcohol is controlling his life. Remaining sober is an important​ goal, but it is not appropriate at this time because the client has not admitted to his problem. Nutritional status is important for the​ client, but the priority goal is recognition of the​ problem, so the nurse can implement other interventions. The client will only participate in AA if he believes that he has a problem with alcohol.

The nurse is collaborating with an outpatient detoxification center for a client who is experiencing acute alcohol withdrawal. Which critical assessment should the nurse make prior to leaving the client at the outpatient center? A) The staff understands how to use the vital sign equipment B) The staff understands how to keep a confused client safe C) The staff is aware of how to administer the medications in the detoxification protocol D) The staff understands signs of severe withdrawal and knows when to notify the HCP

D) The staff understands signs of severe withdrawal and knows when to notify the HCP. Rationale: The​ nurse's role is to promote safety in an outpatient or home setting with a client. In this​ case, the outpatient detoxification center is working from an established protocol. The staff will be educated in how to monitor the​ client's vital​ signs, administer needed​ medications, and keep the client safe. It is the​ nurse's responsibility to ensure that the outpatient center recognizes signs of severe alcohol withdraw and knows when to notify the healthcare provider or to transfer the client to a center with a higher level of acuity.

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" A) 7 days B) 14 days C) 21 days D) Within a few hours (Saunders)

D) Within a few hours Rationale: Early signs of alcohol withdrawal will develop within a few hours after cessation or reduction of alcohol and peak after 24-48 hours

A client discloses that her father was an alcoholic. She is concerned that she will develop alcohol abuse in the future, even though she abstains from drinking. Which questions should be of the highest priority for the nurse to ask at this time? A) "Are you currently employed?" B) "Do you exercise on a regular basis?" C) "Are you able to limit the amount of alcohol you consume?" D) "Do you have a history of depression or mental health difficulties?"

D) "Do you have a history of depression or mental health difficulties?" Rationale: Children of alcoholics​ (COAs) have significantly more mental health difficulties and a higher rate of substance abuse issues. Their families had higher rates of unemployment and unhealthy lifestyle habits when compared with control groups. Asking about mental health demonstrates understanding of the most prominent risk factor for alcohol abuse. Unemployment is a risk​ factor, but mental health is a more significant indicator for future coping. The client states that she does not​ drink, so asking about the amount of alcohol consumed is not a priority question. Assessing for exercise will help determine lifestyle​ habits, but mental health is a higher priority.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? A) Hypotension, ataxia, vomiting B) Stupor, agitation, muscular rigidity C) Hypotension, bradycardia, agitation D) Hypertension, disorientation, hallucinations (Saunders)

D) Hypertension, disorientation, hallucinations Rationale: Symptoms associated with alcohol withdrawal delirium: anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions

The nursing assessment findings for a client with known alcohol abuse include a recent fall at home,decreased appettite, complaints of blurred vision, and believes that alcohol does not have negative effects on the body. Which nursing diagnosis is a priority for the nurse when developing the plan of care for this client? A) Confusion, Chronic B) Nutrition, Imbalanced: Less than body requirements C) Knowledge, Deficient D) Injury, Risk for

D) Injury, Risk for Rationale: The client reported a recent fall at home and has blurred​ vision, so safety is a priority concern.​ Therefore, ​Injury, Risk for is the priority diagnosis. While the client is at risk of nutritional imbalance due to the decreased​ appetite, and the belief that alcohol has no negative effects on the body is a knowledge​ deficit, these matters do not address safety. There is no indication that the client has confusion.​ (NANDA-I ©​ 2014)