Chapter 6 EAQ

Which maximum score would be given to a patient when using the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G)?

10

Which initial scores on the Clinical Institute Withdrawal Assessment (CIWA) would cause the nurse to take vital signs every hour for 8 hours? Select all that apply.

10 14 18

Which score on the Clinical Institute Withdrawal Assessment (CIWA) would cause the nurse to follow the prescribed scheduled medication for treatment of alcohol withdrawal?

16

The nurse asks, "In the past year, how often have you needed a drink first thing in the morning after a night of heavy drinking?" Which Alcohol Use Disorders Identification Test (AUDIT) score would the nurse give to a patient who answers, "Maybe once a month"?

2

Which approximate number of standard drinks would be present in a 22-oz bottle of a malt liquor?

2.5

Which parameter would the nurse be assessing when asking questions 1 through 3 of the Alcohol Use Disorders Identification Test (AUDIT)?

Alcohol consumption

Which type of drinker would have increased levels of serum aspartate aminotransferase (AST)?

Chronic

Which criterion of the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) has 4 as the highest score?

Clouding of sensorium

Which drug intoxication would the nurse assess for in a patient who has dilated pupils, acts superior, and continuously scans the surroundings for threats?

Cocaine

Which associated complication would the nurse expect to find in a retired older patient who is a chronic drinker?

Cognitive decline

Which assessment finding would indicate the patient has a substance abuse problem?

Has an inability to stop using

Which examples are categories of illicit drug use? Select all that apply.

Inhalants Hallucinogens Marijuana

The patient is experiencing tremors of the tongue and eyelids from sedative withdrawal. Which additional findings would the nurse monitor for? Select all that apply.

Insomnia Grand mal seizures Orthostatic hypotension

At a 6-month check-in the patient reports lingering cravings for alcohol, but no symptoms of withdrawal, and no instances of drinking since starting treatment. Which information would the nurse report about the patient's status?

Is in early remission.

Which clinical signs would the nurse observe in a patient who stops taking opioids abruptly? Select all that apply.

Lacrimation Tachycardia

Which behavioral change would the nurse observe in a patient who is abusing benzodiazepines?

Sexual aggressiveness

Which condition is associated with sympathetic system stimulation because of alcohol intake?

Vasoconstriction

Which parameter would the nurse assess to determine the "W" in the TWEAK questionnaire?

Worry

Which questionnaire would the nurse use to assess "at-risk" drinking of alcohol in a pregnant patient?

olerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK)

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)?

"About once a week."

When using the Alcohol Use Disorders Identification Test, which response by the patient to how often during the past year have there been feelings of guilt after drinking would cause the nurse to give a score of 4?

"Almost every day."

Which question would the nurse ask a patient who abuses pain relievers to determine the most frequent method of acquisition?

"Did you get these from a friend or relative?"

Which question would the nurse ask to determine tolerance in a patient who drinks alcohol?

"Have you needed to drink a lot more to get the same effect?"

Which statement made by the male patient alerts the nurse to the possibility of "at-risk" drinking?

"I drink 15 bottles of beer a week, usually with friends."

Which response would the nurse use for a patient who is at-risk for alcohol abuse?

"I strongly recommend that you cut down your drinking."

A nurse asks a male patient, "How many drinks do you consume per week?" Which answers to this question would alert the nurse to the possibility of heavy drinking?

15

When using the Alcohol Use Disorders Identification Test (AUDIT), which score would the nurse give to the patient who consumes alcohol-containing drinks three times a month?

2

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?

3

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

4

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

4

Which maximum score can be given to a patient when using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)?

67

When using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), which score would the nurse give to the patient who constantly has auditory hallucinations?

7

Which parameters would the nurse assess for when using the Alcohol Use Disorders Identification Test (AUDIT)? Select all that apply.

Adverse consequences Alcohol consumption Drinking behavior

For early detection of delirium tremens, which substance would the nurse ask the patient about using?

Alcohol

Which substance is the most used and abused psychoactive drug in the United States?

Alcohol

Which screening test would the nurse administer to a female patient with liver cirrhosis in an intensive care unit (ICU)?

Alcohol Use Disorders Identification Test-C (AUDIT-C)

Which medical condition is a major cause of liver cirrhosis?

Alcohol abuse

Which clinical signs would appear in a patient who is undergoing treatment for nicotine withdrawal? Select all that apply.

Anxiety Frustration Awakening at night

Which illicit drug is most commonly used in the United States?

Cannabis

Which type of substance use would the nurse assess for in a patient who presents with anxiety, dry mouth, and increased appetite, particularly for "junk" food?

Cannabis

Which biomarker would be elevated in a patient who has been drinking 60 grams of alcohol per day for 1 week?

Carbohydrate-deficient transferrin (CDT)

Which medical condition occurs when the patient drinks more than 5 drinks/day?

Cardiomyopathy

When using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, which finding in the tactile disturbances criterion would cause the nurse to give a score of 7 to the patient?

Continuous hallucinations

Which screening instrument uses 4 questions to determine lifetime alcohol abuse and/or dependency?

Cut down, Annoyed, Guilty, Eye-opener (CAGE)

Which action would the nurse take for a patient who scores 6, 5, and 6 on 3 consecutive days on the Clinical Institute Withdrawal Assessment (CIWA)?

Discontinue the assessment.

Which actions would the nurse take to help the patient give reliable data about drug use? Select all that apply.

Ensure that the assessment setting is quiet. Ask the patient questions in a private setting. Assure the patient that any information provided will be kept confidential.

A patient with alcohol abuse presents with delirium tremens exhibiting irregular tremors and tachycardia. Which additional finding would the nurse monitor for?

Fever

Which biochemical parameter would be checked in addition to carbohydrate-deficient transferrin (CDT) levels to improve the accuracy of alcohol abuse in female patients?

Gamma glutamyl transferase (GGT)

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?

Increased level of mean corpuscular volume

A patient with a history of cannabis abuse/intoxication presents with reddened eyes, dry mouth, and tachycardia. Which additional clinical signs would the nurse monitor for? Select all that apply.

Increased perceptions Social withdrawal

Which area would the nurse address to determine run-ins related to a patient's use of alcohol?

Legal problems

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.

Less muscle mass Impaired kidney function Potential drug interactions

Which category of alcohol abuse would the patient be classified as if the nurse assigns a score of 2 when using the Alcohol Use Disorders Identification Test-C (AUDIT-C)?

Low-risk drinking

Which type of withdrawal would the nurse monitor for in a patient who scores a 10 on the Clinical Institute Withdrawal Assessment (CIWA)?

Mild

Which type of drinker would describe a male who consumes two drinks a day?

Moderate

Elevated levels of gamma glutamyl transferase (GGT) in a patient would alert the nurse to which possible conditions? Select all that apply.

Nonalcoholic liver disease Alcohol relapse Chronic alcohol drinking

Which assessment findings obtained by the nurse would indicate a patient is experiencing alcohol intoxication? Select all that apply.

Nystagmus Unsteady gait Flushed face

Which drug would the nurse ask the patient about using when the patient exhibits piloerection, runny nose, and sweating?

Opiate

Which finding would cause the nurse to give a patient a score of 7 on the agitation section of the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)?

Paces back and forth most of the time

Which direct serum biomarker would help detect moderate alcohol intake in a patient?

Phosphatidylethanol

Which situation would cause an alcohol addicted patient's gamma glutamyl transferase (GGT) levels to suddenly increase from normal?

Relapse of alcohol dependency

Which complication would likely develop if a hypertensive patient drinks 3 drinks/day?

Stroke

Which parameters would the nurse assess for when using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)? Select all that apply.

Tremor Headache Visual disturbances