Ch 19 Mental Health

3. Which of the following groups could benefit most from prevention programs? A) Children, prior to first use B) Adults who have already engaged in substance abuse C) Older adults D) Infants

Ans: A Feedback: Poor outcomes have been associated with an earlier age at onset and longer periods of substance use. Children who have not yet used substances may be easily influenced because of their age and the fact that they have not already become addicted. Adults who have already engaged in substance abuse will not benefit as greatly from prevention programs as will children. Older adults will not benefit as greatly from prevention programs as will children. Infants will not benefit from prevention programs as they do not have self-efficacy.

35. Which reasons make it necessary for the nurse to examine his or her beliefs and attitudes about substance abuse? Select all that apply. A) The nurse may be overly harsh and critical of the client. B) The nurse may unknowingly act out old family roles and engage in enabling behavior. C) The nurse or close friends and family of the nurse may abuse substances. D) The nurse may have different attitudes about various substances of abuse. E) The nurse is not likely to have had any experience with substance abuse.

Ans: A, B, C, D Feedback: The nurse must examine his or her beliefs and attitudes about substance abuse. A history of substance abuse in the nurse's family can strongly influence his or her interaction with clients. The nurse may be overly harsh and critical. Conversely, the nurse may unknowingly act out old family roles and engage in enabling behavior. Examining one's own substance use or use by close friends and family may be difficult and unpleasant but is necessary if the nurse is to have therapeutic relationships with clients. The nurse also might have different attitudes about various substances of abuse. Health-care professionals also have higher rates of alcoholism than the general population. With the pervasive nature of substance abuse nationally, odds are great that nurses and other health professionals have been affected by substance abuse in their lives.

1. A community health nurse is planning a substance abuse prevention program. Which group would be the best target audience for the nurse to plan a program? A) Teenagers in a high school health class B) School-age children in an after-school program C) Parents attending a parentñteacher association meeting D) Elementary school teachers and counselors

Ans: B Feedback: Forty-three percent of all Americans have been exposed to alcoholism in their families. Children of alcoholics are four times more likely than the general population to develop problems with alcohol. Many adult people in treatment programs as adults report having had their first drink of alcohol as a young child, when they were younger than age 10. With the increasing rates of use being reported among young people today, this problem could spiral out of control unless great strides can be made through programs for prevention, early detection, and effective treatment.

29. A client will be taking disulfiram (Antabuse) after discharge from an alcohol treatment program. Which statement would indicate that teaching has been effective? A) ìAntabuse is safe to take with any over-the-counter cold medication.î B) ìAntabuse will block my cravings for alcohol, so I'll have less desire to drink.î C) ìDrinking alcohol while taking Antabuse can cause dangerous symptoms.î D) ìIf I drink while taking Antabuse, it will make me vomit before the alcohol affects me.î

Ans: C Feedback: Taking alcohol in any form while taking Antabuse causes a severe adverse reaction. Antabuse is not safe to take with OTC medications. It does not block cravings for alcohol. Antabuse does not restrict the effect of alcohol on the body.

9. The nurse is discussing the principles of 12-step programs for recovery with a client. Which statement is consistent with the principles of 12-step programs? A) The client will need to abstain from all substances for successful recovery. B) Once sober, the person can safely return to life as it was before becoming addicted. C) The prognosis for recovery is enhanced with the aid of maintenance medications. D) Recovery requires adherence to a plan of achieving long-term goals.

Ans: A Feedback: Alcoholics Anonymous (AA) developed the 12-step program model for recovery, which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. Key slogans reflect the ideas in the 12 steps, such as ìone day at a timeî (approach sobriety one day at a time), ìeasy does itî (don't get frenzied about daily life and problems), and ìlet go and let Godî (turn your life over to a higher power). Page 5

32. The nurse is working in an intensive care unit and observes that some clients do not respond to injections of diazepam (Valium) when the injections are given by a particular nurse. This nurse returns from lunch exhibiting slurred speech and euphoria. Which is the best action for the nurse to take? A) Ask other nurses if they have noticed anything unusual. B) Call the manager and report the observations. C) Observe the nurse as injections are prepared and administered. D) Tell the nurse, ìI know you've been stealing Valium.î

Ans: B Feedback: Any suspicions should be communicated to someone in a supervisory position so that effective action can be taken. Page 15

23. The nurse is coleading a family therapy group with a client addicted to alcohol. Which statement made by the wife indicates the need for additional education regarding alcoholism as a family illness? A) ìI have to call in sick for my husband when he is too hung over to go to work.î B) ìLast time he got arrested, I just let him sit in jail.î C) ìWe have separated our finances so that I will not go broke.î D) ìI take my kids with me to Al-anon meetings every week.î

Ans: A Feedback: Alcoholism (and other substance abuse) often is called a family illness. One type of codependent behavior is called enabling, which is a behavior that seems helpful on the surface but actually perpetuates the substance use. Family members should be referred to Al-anon 12-step self-help groups. Page 11

25. A client calls the emergency department of the local hospital reporting that after 16 years of heavy drinking, he is tired and wants to quit ìcold turkey.î What would be the best response by the nurse? A) ìIt is not safe to stop drinking suddenly without medicine.î B) ìYou sound really motivated. Come in and we will help you find a treatment center.î C) ìAfter a few days of rest, you should feel much better as long as you do not drink anything.î D) ìYou will likely feel anxious and get a severe headache. Treat these symptoms with acetaminophen and rest, and come in if they do not get better in 3 to 5 days.î

Ans: A Feedback: Because alcohol withdrawal can be life threatening, detoxification needs to be accomplished under medical supervision. If the client's withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be treated safely at home. For more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting. Some psychiatric units also admit clients for detoxification, but this is less common. Page 12

34. A client is readmitted to the detox unit for the fourth time in 3 years. The nurse states in the morning report, ìNot again! Why should we keep trying to help this guy? He obviously doesn't want it.î What does this statement reflect? A) The nurse lacks the self-awareness to work effectively with this addicted client. B) The nurse understands the cycle of remission and relapse characteristic of addiction. C) The nurse has repressed negative emotions from past experiences with addiction. D) The nurse is trying to conceal his or her own addictions.

Ans: A Feedback: Many clients experience periodic relapses. For some, being sober is a lifelong struggle. The nurse may become cynical or pessimistic when clients return for multiple attempts at substance use treatment. Such thoughts as ìhe deserves health problems if he keeps drinkingî or ìshe should expect to get hepatitis or HIV infection if she keeps doing intravenous drugsî are signs that the nurse has some self-awareness problems that prevent him or her from working effectively with clients and their families. It is not appropriate to assume that the nurse is trying to conceal his or her own addictions. Page 16

5. The nurse is assessing a client's risk factors for developing a substance abuse disorder. Which family characteristics would the nurse identify as a significant risk factor? A) One parent who is an alcoholic B) Parents who practiced strict discipline C) Overprotective parents D) Being raised in an urban area

Ans: A Feedback: The strongest indication of risk factors comes from studies that indicate children of alcoholic parents are four times as likely to develop alcoholism that of nonalcoholic parents. Some theorists also believe that inconsistency in the parent's behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse. Others hypothesize that even children who abhorred their family lives are likely to abuse substances as adults because they lack adaptive coping skills and cannot form successful relationships. Urban areas where drugs and alcohol are readily available also have high crime rates, high unemployment, and substandard school systems that contribute to high rates of cocaine and opioid use and low rates of recovery.

18. A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen in the emergency department. The client is oriented but is tremulous, weak, and sweaty and has some gastrointestinal (GI) symptoms. Which of the following is typical of these symptoms? A) Alcohol withdrawal syndrome B) Continuing intoxication C) Delirium tremens D) WernickeñKorsakoff syndrome

Ans: A Feedback: Withdrawal from alcohol produces shakiness, weakness, diaphoresis, and GI symptoms. These are not symptoms of continuing intoxication. Delirium tremens produce hypertension, delusions, hallucinations, and agitated behavior. Wernicke-Korsakoff syndrome is a type of dementia caused by long-term, excessive alcohol intake that results in a chronic thiamine or vitamin B6 deficiency.

2. Which statements are important reasons for why the problem of substance abuse must be addressed? Select all that apply. A) Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs. B) Chemical abuse results in increased violence. C) Drug abuse costs business and industry an estimated $102 billion annually. D) Alcohol abuse is a too frequent cause of or contributor to death. E) Substance abuse is decreasing.

Ans: A, B, C, D Feedback: Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs. Chemical abuse results in increased violence. Drug abuse costs business and industry an estimated $102 billion annually. Alcohol abuse is a too frequent cause of or contributor to death. Substance use/abuse and related disorders are a national health problem.

31. Which are general warning signs of substance abuse that a nurse should be alert for in coworkers? Select all that apply. A) Poor work performance B) Frequent absenteeism C) Unusual behavior D) Slurred speech E) Isolation from peers F) Substance abuse is not a problem in health professionals

Ans: A, B, C, D, E Feedback: General warning signs of abuse include poor work performance, frequent absenteeism, unusual behavior, slurred speech, and isolation from peers. Physicians, dentists, and nurses have far higher rates of dependence on controlled substances, than other professionals of comparable educational achievement. One reason is thought to be the ease of obtaining controlled substances. Health-care professionals also have higher rates of alcoholism than the general population.

27. The nurse is coleading a family therapy group for clients and families of drug-addicted individuals. The family of a cocaine addict is angry and cannot understand why the client cannot just stop using. The nurse guides the group to discuss their understanding of the nature of addiction. Which statements would the nurse identify as an accurate understanding of the nature of addiction? Select all that apply. A) It is a medical illness that is progressive. B) The client will eventually be cured. C) Relapses and remissions are part of the illness. D) Clients can learn to get control over the substance.

Ans: A, C Feedback: Alcoholism (and other substance abuse) often is called a family illness. All those who have a close relationship with a person who abuses substances suffer emotional, social, and sometimes physical anguish. Client and family members need facts about the substance, its effects, and recovery. The nurse must dispel myths and misconceptions such as, ìIt's a matter of will power,î ìI can't be an alcoholic if I only drink beer or if I only drink on weekends,î ìI can learn to use drugs socially,î or ìI'm okay now I could handle using once in a while.î Page 13

10. Which characteristic of the 12-step program distinguishes it from other programs? A) The philosophy that it is possible to reduce the use of substances without abstaining. B) It is a self-help group that does not necessarily use health professionals as leaders. C) Persons who use this program are independent in their sobriety. D) Infrequent attendance is usually successful.

Ans: B Feedback: Alcoholics Anonymous (AA) was founded in the 1930s by alcoholics. This self-help group developed the 12-step program model for recovery, which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. Regular attendance at meetings is emphasized.

33. A peer reports for work looking unkempt and disheveled. Her movements are uncoordinated, and her breath smells like mouthwash. Another nurse suspects this peer is intoxicated. What should be the action of the nurse who suspects that a peer is intoxicated? A) Immediately call the supervisor to report the peer's behavior. B) Ask the peer if she feels alright and express concern. C) Give the peer some information about the hospital's employee assistance program. D) Ignore the situation until someone else validates the observations.

Ans: B Feedback: Client safety is a priority the impaired nurse should not be caring for clients. After client safety is ensured, the nurse should call the supervisor to handle the situation. It is not the nurse's responsibility to give out information on the hospital's employee assistance program. It is not appropriate to ignore the situation.

14. A client is being discharged from treatment for addiction to cocaine. Which statement made by the client would cause the most concern for the nurse? A) ìI am going to take up a new hobby. It's time to start something new.î B) ìI can still hang out with my old friends. I am just not going to use.î C) ìI'm not very comfortable with being alone yet.î D) ìShooting baskets helps me not think about getting high.î

Ans: B Feedback: Clients are likely to have exercised poor judgment. They may still believe they can control the substance use. The nurse can help clients to find ways to relieve stress or anxiety that do not involve substance use. Relaxing, exercising, listening to music, or engaging in activities may be effective. Clients also may need to develop new social activities or leisure pursuits if most of their friends or habits of socializing involved the use of substances. Acknowledging difficulties shows insight into the changes needed for recovery. Assuming that old friends will not be a relapse trigger shows a lack of understanding of the relapse dynamics associated with former leisure activities.

7. The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse that his relationship with the client was codependent and enabling. Which is an example of codependent behavior? A) The friend called Alcoholics Anonymous when the client expressed a need to stop drinking. B) The friend called the client every night to make sure he got home safely and went looking for him if he was not at home. C) The friend confronted the client on the effect of his drinking on their relationship. D) The friend refused to go out drinking with the client to celebrate the client's birthday.

Ans: B Feedback: Codependent behavior appears helpful on the surface but actually prolongs the drinking behavior. The other choices are not examples of codependent behavior.

17. A nurse is exploring treatment options with a client addicted to heroin. Which information regarding the use of methadone is important for the nurse to include? A) Unlike heroin, methadone is nonaddicting. B) Methadone will meet the physical need for opiates without producing cravings for more. C) Methadone will produce a high similar to heroin. D) People taking methadone run the same risks associated with IV drug use as those taking heroin.

Ans: B Feedback: Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs. The client takes one daily dose of methadone, which meets the physical need for opiates but does not produce cravings for more. Methadone does not produce the high associated with heroin. The client has essentially substituted his or her addiction to heroin for an addiction to methadone however, methadone is safer because it is legal, controlled by a physician, and available in tablet form. The client avoids the risks of intravenous drug use, the high cost of heroin (which often leads to criminal acts), and the questionable content of street drugs. Page 9

30. A nurse suspects a coworker is signing out narcotics for clients and is using them herself. Which action should be taken by the nurse who has these suspicions? A) Ignore suspicions and leave it to the supervisor to intervene. B) Report the observations to the supervisor. C) Follow behind the coworker to ensure client comfort and safety. D) Confront the coworker about suspicions.

Ans: B Feedback: Nurses have an ethical responsibility to report suspicious behavior to a supervisor and, in some states, a legal obligation as defined in the state's nurse practice act. Nurses should not try to handle such situations alone by warning the coworker this often just allows the coworker to continue to abuse the substance without suffering any repercussions. Page 14

19. A client with alcohol dependence is admitted to the hospital with pancreatitis. Which intervention should be included in the client's plan of care? A) Fluid restriction of 1000 mL per 24 hours B) Glucometer checks b.i.d. C) High-protein diet D) Protective isolation precautions

Ans: B Feedback: Pancreatitis can cause elevated serum glucose levels. The other choices are not necessarily appropriate.

8. When interviewing the family members of a client being treated for substance abuse problems, which behavior would alert the nurse to the possibility of codependency? A) Being flexible but angry B) Blaming themselves for the family's problems C) Expressing thoughts and feelings openly D) Taking pleasure in self-accomplishments

Ans: B Feedback: Self-blame is an example of maladaptive coping or codependent behavior. The other choices do not correlate with codependency behaviors.

21. A client is readmitted to the substance abuse program for the second time in 6 months for alcohol abuse. On admission, he tells the nurse, ìI am so ashamed.î What should the nurse reply? A) ìI really thought you would make it.î B) ìTell me what has happened since your last admission.î C) ìYou have nothing to be ashamed of.î D) ìWhy did you start drinking again?î

Ans: B Feedback: This is a therapeutic communication technique designed to help the client talk about himself and his current situation.

6. A client reports drinking one to two drinks when drinking behavior first began. Now the client reports drinking at least six drinks with every episode in order to ìhave a good time.î Which term would best describe this phenomenon? A) Dependence B) Intoxication C) Tolerance D) Withdrawal

Ans: C Feedback: As the person continues to drink, he or she often develops a tolerance for alcohol that is, he or she needs more alcohol to produce the same effect. Intoxication is use of a substance that results in maladaptive behavior. Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases. Substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.

24. A nurse is working with a couple seeking counseling for marital discord. The history indicates the husband was treated for substance abuse 4 years ago and attends AA meetings occasionally. Which statement made by the recovering husband should alert the nurse for the need for further education? A) ìI still need to go to AA meetings even though I have been sober for years.î B) ìAfter all these years, I just don't have the will power to stop if I started using again.î C) ìShe gets upset when I hang out with my old buddies on the weekends.î D) ìI wish I could be able to handle just one beer with dinner.î

Ans: C Feedback: Family members and friends should be aware that clients who begin to revert to old behaviors, return to substance-using acquaintances, or believe they can ìhandle myself nowî are at high risk for relapse, and loved ones need to take action. The nurse must dispel myths and misconceptions such as, ìIt's a matter of will power,î ìI can't be an alcoholic if I only drink beer or if I only drink on weekends,î ìI can learn to use drugs socially,î or ìI'm okay now I could handle using once in a while.î

12. The nurse is assessing the drinking history of a client being admitted for alcohol abuse. Which statement would the nurse expect the client to make? A) ìI really need some help. My drinking is tearing my family apart.î B) ìI have tried so many times to stop drinking. It is so hard.î C) ìI don't really have a problem with alcohol. I've just been having a streak of bad luck lately.î D) ìI have no intention to stop drinking. I like the way it makes me feel.î

Ans: C Feedback: Substance use typically includes the use of defense mechanisms, especially denial. Clients may deny directly having any problems or may minimize the extent of problems or actual substance use. During assessment of thought process and content, clients are likely to minimize their substance use, blame others for their problems, and rationalize their behavior. They may believe that they could quit ìon their ownî if they wanted to, and they continue to deny or minimize the extent of the problem. Upon admission, the nurse would not expect the client have the insight to know how badly help is needed, or to express powerlessness over alcohol. The client would have some motivation for treatment if admission was underway. Often the motivation is external, such as pressure from family or employers.

15. A client is being discharged on disulfiram (Antabuse). Which instruction for Antabuse should the client receive? A) Take disulfiram with food to avoid stomach upset. B) Skip the daily dose of disulfiram on days when consumption of alcoholic beverages is likely. C) Read products labels carefully to avoid all products containing alcohol. D) Disulfiram will prevent the desire to drink alcoholic beverages.

Ans: C Feedback: The client must avoid a wide variety of products that contain alcohol such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla and other extracts. The client must read product labels carefully, because any product containing alcohol can produce symptoms. Ingestion of alcohol may cause unpleasant symptoms for 1 to 2 weeks after the last dose of disulfiram. Page 8

11. Which slogans would be used in a 12-step program? Select all that apply. A) ìPull yourself together.î B) ìGet control of your problem.î C) ìOne day at a time.î D) ìEasy does it.î E) ìLet go and let God.î

Ans: C, D, E Feedback: Before the illness of addiction was fully understood, most of the society and even the medical community viewed chemical dependency as a personal problem the user was advised to ìpull yourself togetherî and ìget control of your problem.î Key slogans in AA reflect the ideas in the 12 steps, such as ìOne day at a timeî (approach sobriety one day at a time), ìeasy does itî (don't get frenzied about daily life and problems, and ìlet go and let Godî (turn your life over to a higher power). Page 6

20. A client is admitted for a drug overdose with a Barbiturate? Which is the priority nursing action when planning care for this client? A) Check the client's belongings for additional drugs. B) Pad the side rails of the bed because seizures are likely. C) Prepare a dose of ipecac, an emetic. D) Monitor respiratory function.

Ans: D Feedback: CNS depressants depress respiratory functioning. Answer choices A, B, and C would not be priority nursing actions in this situation. Page 10

13. A client in treatment for drug abuse makes the statement, ìI am a winner. You all are the losers because you can't beat this on your own.î What common characteristic of persons addicted to drugs is revealed in this statement? A) Realistic understanding of successful recovery of drug addiction B) Indication of an underlying personality disorder C) Brain damages resulting from chronic drug use D) Defending against a negative self-concept

Ans: D Feedback: Clients generally have low self-esteem, which they may express directly or to cover with grandiose behavior. They do not feel adequate to cope with life and stress without the substance and often are uncomfortable around others when not using. They often have difficulty identifying and expressing true feelings. Page 7

16. The client asks the nurse, ìWhat will happen if I drink while taking Antabuse?î What should be the nurse's reply? A) ìYou will not want to drink while taking Antabuse. It reduces the cravings.î B) ìYou will not get any effect from the alcohol you drink.î C) ìAntabuse will reverse the effects of alcohol.î D) ìYou will experience a severe reaction, including a throbbing headache and vomiting.î

Ans: D Feedback: Disulfiram (Antabuse) may be prescribed to help deter clients from drinking. If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, sweating, nausea, and vomiting. In severe cases, severe hypotension, confusion, coma, and even death may result.

28. The wife of a client who is alcoholic asks the nurse how to respond to him in a helpful way when he is disruptive in family life. Which is the nurse's best response? A) ìHelp him avoid embarrassment by supporting him when he makes excuses for failing to meet obligations.î B) ìInclude him in family outings even when he is drinking.î C) ìSearch the house regularly for alcohol.î D) ìTry to maintain a normal home environment for yourself and the children.î

Ans: D Feedback: Focusing on self and family members is the first step in breaking codependent behavior. Answer choices A, B, and C would not be the best response.

26. An unconscious client is admitted to the emergency department after a motor vehicle accident. The client's blood alcohol level upon admission was 1.7. The client's family soon arrives, reporting that the client is an uncle who is visiting from out of town. They cannot give much more history other than that he is a ìsocial drinker.î After being transported to the unit, the client starts sweating and has elevated vital signs. What information should the nurse request of the family? A) Who is the next of kin? B) For what occasion is the uncle visiting from out of town? C) Does the uncle have a history of any sort of anxiety disorder? D) Are there other indications that the client may be a heavy drinker?

Ans: D Feedback: It is important to assess the situation thoroughly and since the client is unconscious, he cannot communicate what is happening to the staff. The best chance for the staff to understand what is going on would be to inquire further of the relatives. If the client is experiencing withdrawal, detoxification needs to be initiated immediately under medical supervision. Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or deliriumócalled delirium tremens (DTs). Alcohol withdrawal usually peaks on the second day and is over in about 5 days.

4. Which of the following neurochemical influences is a probable cause of substance abuse? A) Imbalances of serotonin and norepinephrine in the brain B) Inhibition of GABA in the brain C) Excessive serotonin activity in the CNS D) Stimulation of dopamine pathways in the brain

Ans: D Feedback: Neurochemical influences on substance use patterns have been studied primarily in animal research (Jaffe & Anthony, 2005). The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a ìhighî that is a reinforcing, or positive, experience. Page 3

22. A client has been admitted to the inpatient unit after using inhalants recently. Which is an antidote to treat inhalant toxicity? A) Ativan B) Narcan C) Antabuse D) There is no antidote

Ans: D Feedback: There is no antidote or specific medication to treat inhalant toxicity. Ativan, Narcan, and Antabuse are not used to treat inhalant toxicity.