HC3B Exam 4
The CAGE questionnaire is used to screen the client's use of which substance? A) Alcohol B) Barbiturates C) Hallucinogens D) Multiple drugs
A) Alcohol
A physician informed an adult of the results of diagnostic tests that showed lung cancer. Later in the day, the patient says to the nurse, "My doctor said I have breathing problems, right?" Which nursing diagnosis is applicable? A) Denial related to acceptance of new diagnosis B) Spiritual distress related to unresolved life conflicts C) Situational low self-esteem related to stress of new diagnosis D) Acute confusion related to metastatic changes to cerebral function
A) Denial related to acceptance of new diagnosis
In the rehabilitation of a client addicted to alcohol, which factor is most important? A) Motivational readiness B) Availability of community resources C) Accepting attitude of the family D) Level of the client's physical state
A) Motivational readiness
16 years ago a toddler died in a tragic accident. Once a year, the parents place flowers at the accident site. How would the nurse characterize the parent's behavior? A) Mourning B) Bereavement C) Complicated grief D) Disenfranchised grief
A) Mourning
Which best approach would the nursing staff use to handle a nurse's return after completing a drug rehabilitation program? A) Offering the nurse support in a straightforward manner B) Avoiding mentioning the problem unless the nurse brings it up C) Having another staff member keep the nurse under close observation D) Ensuring that the nurse is assigned to administer only non-controlled medications
A) Offering the nurse support in a straightforward manner
Which rationale best explains how addiction to alcohol occurs? A) Person eventually requires alcohol for functioning B) Person lacks the motivation or will to stop drinking C) Person has developed very few coping mechanisms D) Person enjoys the social aspects of drinking alcohol
A) Person eventually requires alcohol for functioning
Which nursing action would be the primary consideration when caring for a client with a substance use disorder? A) Setting firm, consistent limits and not varying from them B) Using the same type of communication pattern that the client uses C) Avoiding upsetting the client by calling attention to the drug problem D) Realizing that the client will probably need less pain medication than a non-abuser would
A) Setting firm, consistent limits and not varying from them
Which intervention would the nurse use in the care of a drug-dependent mother and infant? A) Support the mother's positive responses toward her infant B) Request that family members share responsibility for infant care C) Separate the infant from the mother until the mother is drug free D) Explain the relationship of infant's symptoms to the mother's drug abuse
A) Support the mother's positive responses toward her infant
Which information would the nurse include as the main reason for drinking alcohol in people with alcohol use disorder? A) They are dependent on it B) They lack the motivation to stop C) They use it for coping D) They enjoy the associated socialization
A) They are dependent on it
Which imbalance is associated with alcohol-induced amnestic disorder? A) Thiamine deficiency B) A reduced iron intake C) An increase in serotonin D) Riboflavin malabsorption
A) Thiamine deficiency
Which rationale would explain the reason a client abuses alcohol? A) To blunt reality B) To precipitate euphoria C) To promote social interaction D) To stimulate the CNS
A) To blunt reality
Which initial outcome criterion would be appropriate for a client who is a poly-substance abuser and is mandated to seek drug and alcohol counseling? A) Verbalizes that a substance abuse problem exists B) Discusses the effect of drug use on self and others C) Explores the use of substances and problematic behaviors D) Expresses negative feelings about the current life situation
A) Verbalizes that a substance abuse problem exists
Which substance(s) can cause life-threatening dysrhythmias when inhaled? SATA. A) Glue B) Gasoline C) Nicotine D) Cannabis E) Paint thinner
A, B, E
The nurse is caring for a client with a sealed radiation implant for the treatment of cancer. Which nursing intervention is appropriate? SATA. A) Place a caution sign on the door of the client's room B) Wear a dosimeter badge for protection when providing care C) Allow the client's spouse to stay with the client at least 6 feet away for 4 hours D) Do not allow children to visit the client for any length of time E) Keep the door to the client's room closed
A, D, E
The nurse has delegated care for a client with a radical left mastectomy for breast cancer to UAP. Which UAP action requires nursing intervention? SATA. A) Obtains blood pressure via left arm B) Reports client's pain level to the nurse C) Applies gait belt prior to walking with the client D) Records vital signs in the electronic health record E) Assists client to administer patient-controlled analgesia
A, E
Which response would the nurse make to the wife of a client with alcohol use disorder who says, "When the drinking starts it really disrupts my family, and I'm not sure how to handle it."? A) "Include your husband in the family's activities even when he's been drinking." B) "Attend Al-Anon meetings and avoid assuming responsibility for your husband's behavior." C) "Search the house regularly for hidden alcohol and accompany your husband outside the home." D) "Help your husband avoid embarrassment by making excuses for him when it's impossible for him to function."
B) "Attend Al-Anon meetings and avoid assuming responsibility for your husband's behavior."
A patient tells the nurse, "After many years, I finally quit smoking. Now I use e-cigarettes only." Which is an appropriate response? A) "Using e-cigarettes is now more socially acceptable than using traditional cigarettes." B) "Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals." C) "Nicotine is a powerful addiction. Quitting smoking is a big step toward adopting a healthier lifestyle." D) "I am glad you have quit smoking. Your loved ones will no longer be exposed to the hazards of second-hand smoke."
B) "Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals."
The nurse is teaching a client who has been prescribed an oral chemotherapy agent. What teaching will the nurse include? A) "Oral chemotherapy drugs are not as toxic as IV chemotherapy." B) "Do not crush, split, break, or chew the oral chemotherapy drug." C) "You may dispose of unused oral chemotherapy drugs in the trash." D) "Oral chemotherapy drugs are not absorbed through the skin."
B) "Do not crush, split, break, or chew the oral chemotherapy drug."
Which is the best response the nurse would make to a male client who is denying addiction to alcohol but says that it is his nagging wife causing him to drink? A) "I don't think that your wife is the problem." B) "Everyone is responsible for his own actions." C) "Perhaps you should have marriage counseling." D) "Why do you think that your wife is the cause of your problems?"
B) "Everyone is responsible for his own actions."
Which of these questions is included on the CAGE screening test for alcoholism? A) "Do you feel that you are a normal drinker?" B) "Have you ever felt bad or guilty about your drinking?" C) "Are you always able to stop drinking when you want to?" D) "How often did you have a drink containing alcohol in the past year?"
B) "Have you ever felt bad or guilty about your drinking?"
Which response would the nurse make to a client who says, "I like the high I get when I huff paint. Nothing bad is going to happen to me."? A) "Inhalants can cause a mild states of intoxication." B) "Huffing paint can damage your lungs, kidneys, and liver." C) "Withdrawal problems will start if you continue huffing paint." D) "Limiting the type of inhalant used decreases respiratory irritation."
B) "Huffing paint can damage your lungs, kidneys, and liver."
The nurse is teaching about infection prevention to a client with cancer who is neutropenic. Which client statement indicates a need for additional teaching? A) "I will call the HCP if I get a temperature of 100.4 or greater." B) "I will wash my hands after attending church." C) "I will wear a condom when having intercourse." D) "I will not drink anything that has been at room temperature for more than an hour."
B) "I will wash my hands after attending church."
A client receiving palliative care for a terminal cancer diagnosis asks the nurse, "Why is this happening to me?" What is the best nursing response? A) "I don't know. God knows when your time is up on this earth." B) "I'm sorry. I know that this is a very difficult time for you." C) "It's going to be okay; at least you aren't leaving any family behind." D) "We'll make sure that all of your needs are met, so don't worry."
B) "I'm sorry. I know that this is a very difficult time for you."
The family of a client experiencing terminal dehydration requests that intravenous fluids be started. What is the nurse's best response? A) "We can start fluids to help ease the dehydration." B) "IV fluids can increase discomfort for the client." C) "IV fluids will likely prolong life." D) "Terminal dehydration can be managed better with pain medication."
B) "IV fluids can increase discomfort for the client."
When caring for four clients, which individual does the nurse identify as being at the highest risk for development of breast cancer? A) 33-year-old male with gynecomastia and obesity B) 45-year-old female whose mother has breast cancer C) 60-year-old male whose father died from colon cancer D) 72-year-old female who was treated for breast cancer 3 years ago
B) 45-year-old female whose mother has breast cancer
As a client addicted to cocaine withdraws from the drug, which behavior would the nurse observe? A) Excitability B) Depression C) Disinhibition D) Hyperactivity
B) Depression
An individual is found unconscious and is admitted to the hospital with heroin overdose. Which nursing action is the priority? A) Monitoring LOC B) Establishing a patent airway C) Monitoring for heroin withdrawal D) Establishing a therapeutic relationship
B) Establishing a patent airway
Which food choices would indicate the client with alcohol use disorder understands the teaching about foods high in thiamine? A) Fish, aged cheese, and breads B) Lean beef, organ meat, and nuts C) Poultry, milk products, and eggs D) Green vegetables, lentils, and citrus fruits
B) Lean beef, organ meat, and nuts
Which initial action would the nurse take for a client admitted to an alcohol rehabilitation center who on the fourth day after admission has a strong odor of alcohol on their breath? A) Ask where the client got the alcohol B) Locate the alcoholic substance C) Convey the staff's disappointment in this behavior D) Document the client's drinking
B) Locate the alcoholic substance
A nurse who has worked for a community hospice organization for 8 years says, "My patients and their families experience overwhelming suffering. No matter how much I do, it's never enough." Which problem should the nursing supervisor expect? A) The nurse is experiencing spiritual distress B) The nurse is at risk for burnout and compassion fatigue C) The nurse is not receiving adequate recognition from others D) The nurse is at risk for overhelping, which creates dependency
B) The nurse is at risk for burnout and compassion fatigue
Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the HCP? A) Temperature of 99°F B) Tingling sensation in the right arm C) Impaired range of motion in the right arm D) Drainage of 20 mL collected over 24 hours
B) Tingling sensation in the right arm
Which initial statement would the nurse use when a client with a history of alcoholism returns to a previously attended residential alcohol treatment program? A) "It's too bad that you failed. What could you do to make things better?" B) "You could die if you keep drinking. Nobody wants to see that happen." C) "You've made progress; let's focus on strategies to prevent a relapse." D) "The program won't work unless you comply with recommendations."
C) "You've made progress; let's focus on strategies to prevent a relapse."
A client returning to the clinic 7 weeks after hematopoietic stem cell transplantation for leukemia has a total white blood cell count of 5200 and a neutrophil count of 3000. What is the nurse's priority action in view of these values? A) Notify the oncology HCP immediately B) Assess the client for other symptoms of infection C) Document the lab report as the only action D) Obtain a urine specimen, sputum specimen, and chest x-ray
C) Document the lab report as the only action
A young adult tells the nurse, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the nurse provide to this patient? A) Guidance that the prescription should not be shared with peers B) Directions to weigh self once a week and maintain a log of the results C) Instructions about safety issues associated with driving or operating machinery D) Information about the potential for amotivational syndrome and memory problems
C) Instructions about safety issues associated with driving or operating machinery
The nurse at a local clinic reviews phoned-in requests from patients for prescription refills. As the nurse confers with the health care provider about which prescription refill requests should be authorized, which refill request should be considered first? A) Codeine 10 mg PO q4h PRN for an adult with a persistent cough B) Hydroxyzine (Vistaril) 25 mg PO TID PRN for an adult who experiences uncomfortable muscle spasms C) Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety D) Lomotil 2 mg PO q6h PRN for an adult experiencing severe diarrhea
C) Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety
Which serious effect of inhalant use would the school nurse include in a teaching session to a high school class about inhalant abuse? A) Esophageal varices B) Dehydration C) Extrapyramidal tract symptoms D) Death
D) Death
Which information would the nurse include in client education regarding alcoholic blackouts? A) It is a fugue state resembling absence seizures B) It is fainting spells followed by loss of memory C) It is a loss of consciousness lasting less than 10 minutes D) It is an absence of memory in relation to drinking episodes
D) It is an absence of memory in relation to drinking episodes
Which drug would the nurse ask the client about using when presenting to the ED with increased energy, irritability, hypertension, and hyperthermia? A) Alcohol B) Heroin C) Oxycodone D) Methamphetamine
D) Methamphetamine
Which assessment finding will the nurse report to the HCP for a client who had an orchiectomy and laprascopic radical retroperitoneal lymph node dissection this morning? A) BP 130/80, T 98.9°F, R 16, P 70 B) Urinary catheter draining clear yellow urine C) Expresses fearfulness of inability to perform sexually D) Reports pain of 9 on a 0-10 scale after receiving pain medication
D) Reports pain of 9 on a 0-10 scale after receiving pain medication
Which intervention would provide comfort to the client experiencing alcohol toxicity? A) Dim the lights B) Use distraction C) Offer activities D) Stay with the client
D) Stay with the client
A recently widowed adult says, "I've been calling my neighbors often, but they act like they don't want to talk to me. I just need to talk about it, you know?" What's the nurse's best action? A) Say to the person, "You may call me anytime you need to talk." B) Ask the person, "What do you mean by 'I just need to talk about it'?" C) Educate the person about the importance of finding alternative activities D) Tell the person the location and time of a local bereavement support group
D) Tell the person the location and time of a local bereavement support group
Which behavior would indicate that a client with a long-term history of alcohol use disorder is ready for treatment? A) Drinking only socially B) Avoiding drinking for a week C) Being hospitalized for detoxification D) Verbalizing an honest desire for help
D) Verbalizing an honest desire for help
When providing discharge teaching about mouth care, which substance will the nurse teach the client with oral cancer to avoid? SATA. A) Mouthwash B) Lip lubricant C) Warm asline rinses D) Ultra-soft toothbrush E) Disposable foam brushes F) Bicarbonate mouth rinse
A, E
A client with chemotherapy induced neutropenia is prescribed filgrastim. The client states, "The bones in my legs are aching so bad." What is the appropriate nursing response? A) "The pain in your legs is likely from the cancer." B) "Bone pain is a side effect of filgrastim that improves with time." C) "Increasing activity will help with the bone pain." D) "Have you had any fever or nausea?"
B) "Bone pain is a side effect of filgrastim that improves with time."
Which type of group is Alcoholics Anonymous (AA)? A) Social group B) Self-help group C) Resocialization group D) Psychotherapeutic group
B) Self-help group
A client has been instructed to stop smoking. Which action would the nurse take upon discovering a pack of cigarettes in the client's bathrobe? A) Notify the HCP B) Report this to the nurse manager C) Tell the client about finding the cigarettes D) Discard the cigarettes without telling the client
C) Tell the client about finding the cigarettes
A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A) The light pink color of the lesion is the same in both photographs B) The lesion has almost disappeared by the time of the second photograph C) The lesion borders have expanded and are shaped differently in the second picture D) The lesion's well-approximated margins and size look no different in either photograph
C) The lesion borders have expanded and are shaped differently in the second picture
The nurse is assessing a client who has advanced bone cancer. Which client assessment finding(s) causes the nurse to suspect spinal cord compression? SATA. A) Reports of a headache for the past 7 hours B) Decreased breath sounds in the left lung C) Worsening mid-thoracic back pain D) Tingling in the right lower extremity E) Unsteady gait when ambulating to the bathroom F) Reports of difficulty sleeping
C, D, E
A young adult has reported heavy use of alcohol and prescription drugs since mid-adolescence. This individual now has an ataxic gait and uses a cane. Which comment by the nurse presents reality while demonstrating compassion? A) "I know you must feel self-conscious about using a cane at your age, but it will help prevent falls." B) "Addiction is a fatal disease. If you continue to drink like you have done in the past, you will not live another 10 years." C) "It's time to face your addiction. You are disappointing your family and must stop drinking for the sake of the people who love you." D) "Addiction is powerful. You are young yet you cannot walk without a cane. Your health has been significantly affected by your long-term use of drugs and alcohol."
D) "Addiction is powerful. You are young yet you cannot walk without a cane. Your health has been significantly affected by your long-term use of drugs and alcohol."
A nurse leads a bereavement group. Which participant's comment best demonstrates that the work of grief has been successfully completed? A) "Our time together was too short. I only wish we had done more things together." B) "I know our life together was a blessing that I did not deserve. I wish I had said 'I love you' more often." C) "Other people knew my loved one as a good and helpful person. I hope people see me in the same way." D) "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."
D) "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."
Which action would be required of the client with alcohol use disorder who attends AA meetings? A) Speaking aloud at weekly meetings B) Maintaining controlled drinking after 6 months C) Promising to attend at least 12 meetings yearly D) Acknowledging an inability to control the alcoholism
D) Acknowledging an inability to control the alcoholism
Which behavior is expected of members of Alcoholics Anonymous (AA)? A) Speaking at and participating in weekly meetings B) Promising to attend at least 12 meetings yearly C) Maintaining controlled drinking after 6 months D) Acknowledging an inability to control the drinking
D) Acknowledging an inability to control the drinking
Which strategy would the nurse recommend that is most effective for a client who has decided to stay sober after completing alcohol detoxification and rehabilitation treatment? A) Daily administration of disulfiram B) Individual or group psychotherapy C) Admission to an alcoholic unit in a hospital D) Active membership in Alcoholics Anonymous
D) Active membership in Alcoholics Anonymous
A client with prostate cancer is receiving external beam radiation for treatment. What teaching will the nurse provide following the radiation treatment? A) "After the treatment, there is no radiation hazard to others." B) "Do not share a bathroom with your spouse for 2 days." C) "Visitors should be limited to 30 minutes to avoid prolonged radiation exposure." D) "Report a temperature of 99.1°F to the primary health care provider."
A) "After the treatment, there is no radiation hazard to others."
A nurse is caring for four clients. Which individual does the nurse identify as being at the highest risk for development of oral cancer? A) 28-year-old with HPV infection B) 30-year-old with recurrent aphthous stomatitis C) 55-year-old who quit chewing tobacco 5 years ago D) 76-year-old who is sometimes negligent in denture care
A) 28-year-old with HPV infection
Which strategy would be effective for a client with alcohol use disorder who says, "Drinking is a way out of my depression."? A) A self-help group B) Psychoanalytical therapy C) A visit with a religious advisor D) Talking with an alcoholic friend
A) A self-help group
For Alcoholics Anonymous, which goal is the priority? A) Acknowledging and changing destructive behavior B) Developing functional social and family relationships C) Identifying how people present themselves to others D) Understanding interactional patterns within the group
A) Acknowledging and changing destructive behavior
For a person who has an alcohol abuse problem, which rationale supports family involvement in the treatment program? A) Alcoholism involves the entire family and affects all members B) Alcoholics try to hide their drinking from their families C) Family members provide insights into the dynamics behind the drinking D) Family members have been most successful in providing necessary support
A) Alcoholism involves the entire family and affects all members
Which medication should the nurse teach the patient to avoid any type of alcohol including mouth washes and hand sanitizers containing alcohol due to a risk of them getting very sick? A) Antabuse B) Methadone C) Clonidine D) Nalmefene
A) Antabuse
When planning for a client's care during the detoxification phase of early alcohol withdrawal, which action would the nurse take? A) Check on the client frequently B) Keep the client's room lights dim C) Address the client in a loud, clear voice D) Restrain the client during periods of agitation
A) Check on the client frequently
Which defense mechanism is most commonly used by client who are alcoholics? A) Denial B) Projection C) Displacement D) Compensation
A) Denial
When caring for a 28-year-old healthy client, how frequently does the nurse recommend a clinical breast examination (CBE)? A) Every 3 years B) At each annual physical C) Not until age 30, as the risks are low D) To begin at age 40 when risks increase
A) Every 3 years
Which substance produces sneezing, yawning, and tearing of the eyes as withdrawal occurs? A) Heroin B) Cocaine C) Morphine D) Phenobarbital
A) Heroin
Which substance(s) are considered addictive according to the DSM-5? SATA. A) Alcohol B) Caffeine C) Cannabis D) Gambling E) Hallucinogens F) Antianxiety medications
A, B, C, D, E, F
The nurse is assisting the UAP provide care to a client who is neutropenic. Which action by the UAP requires the nurse to intervene? A) Performing a bed bath because the client is too tired to get in the shower B) Using the unit mobile blood pressure machine to assess the client's vital signs C) Using alcohol-based hand foam before touching the client D) Cleaning the client's bathroom with disinfectant
B) Using the unit mobile blood pressure machine to assess the client's vital signs
Which clinical manifestations accompany methamphetamine use? SATA. A) Bradypnea B) Tachycardia C) Hyperthermia D) Constricted pupils E) Decreased blood pressure
B, C
Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? SATA. A) Encourage client to accept her new body image B) Provide self-care resources to the primary caretaker C) Teach client about birth control options that are available D) Refer to support groups for people who have had a mastectomy E) Involve partner in discussions about sexuality if client desires
B, C, D, E
A client receiving radiation for head and neck cancer reports that the skin in the radiation field is itching and painful. What teaching will the nurse provide? SATA. A) "This is likely from medication, not the radiation treatment." B) "Cover the area with soft clothing." C) "Be sure to wash your hands well before touching the area." D) "Sunlight to the radiated area can help the skin heal." E) "Use a washcloth to thoroughly clean the area with soap and water." F) "Do not remove the ink markings on the skin."
B, C, F
A nurse teaches a patient with alcohol use disorder about a new prescription for naltrexone. Which comment by the patient indicates the teaching was effective? A) "This medicine will stop my cravings for alcohol." B) "I should take this medication only when I feel cravings to drink alcohol." C) "This medicine is one part of a bigger treatment plan to help me stay sober." D) "I should not use products that contain alcohol, such as cough medicine and aftershave lotion."
C) "This medicine is one part of a bigger treatment plan to help me stay sober."
Which substance would pose the greatest risk of addiction for clients attending an alcohol rehabilitation program? A) Heroin B) Cocaine C) Nicotine D) Phencyclidine
C) Nicotine
Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? A) Infuse IV fluids B) Monitor the level of anxiety C) Obtain frequent vital signs D) Administer chlordiazepoxide
D) Administer chlordiazepoxide
Which response would the nurse use when a client is observed hiding a bottle of whiskey in the back of a drawer? A) Wait and try to catch the client drinking alcohol B) Confiscate the alcohol when the client is not looking C) Wait for the client to bring up the subject of drinking D) Ask the client how much alcohol she or he consumes in a week
D) Ask the client how much alcohol she or he consumes in a week
Which of the following medications is used for detoxification and longer-term maintenance for opioid addiction? A) Naloxone (Narcan) B) Nalmefene (Revex) C) Clonidine D) Buprenorphine (Suboxone)
D) Buprenorphine (Suboxone)
Which mental mechanism would the nurse suspect when a client with alcohol use disorder who has not worked for the past 10 years states, "I currently work in the office of a local construction company?" A) Regression B) Sublimation C) Compensation D) Confabulation
D) Confabulation
