HESI CS - Alcoholism

Eight hours after admission, a new nurse is assigned to care for the client. After receiving report, the nurse reviews the recent information in the chart.

Vital Signs Blood pressure 146/98 mmHg Heart rate 100 beats/min Respirations 22 breaths/min Temperature 99.8° F (37.7° C) Laboratory Data AST: 80 U/L (1.34 µkat/L) ALT: 96 U/L (1.60 µkat/L) Sodium: 145 mEq/L (145 mmol/L) Potassium: 3.6 mEq/L (3.6 mmol/L) Prescriptions 1. Perform withdrawal assessment every 4 hours. 2. Lorazepam 2 mg PO every 6 hours prn per alcohol withdrawal protocol. 3. Continue suicide precautions. The nurse performs the withdrawal assessment and observes moderate tremors. The client reports nausea.

What mechanism of action accounts for symptoms of alcohol withdrawal delirium? a. Increased dopamine. b. Increased GABA. c. Decreased norepinephrine. d. Increased serotonin.

A Alcohol intake represses gamma-aminobutyric acid (GABA), which inhibits dopamine. When alcohol is eliminated, dopamine rebounds above the normal level, resulting in excitation and alterations in thought, perception, and orientation. (B) Increased GABA will have a calming effect. (C) Decreased norepinephrine results in fatigue, the inability to experience pleasure, and feeling "blah." (D) Increased serotonin results in feelings of happiness and boosts feelings of self-esteem and self-confidence.

What is the therapeutic action of benzodiazepines? a. Potentiate the effects of GABA. b. Block the reuptake of dopamine. c. Block the reuptake of serotonin. d. Activate opioid receptors.

A Benzodiazepines potentiate the effects of GABA, which has a calming effect. (B) Benzodiazepines do not block the reuptake of dopamine. Blocking the reuptake of dopamine prolongs the action of dopamine and causes excitation. (C) Benzodiazepines do not block the reuptake of serotonin. Serotonin increases feelings of happiness, self-esteem, and self-confidence and also helps to decrease impulsive behavior. (D) Benzodiazepines do not activate opioid receptors.

When should the nurse begin assessing for withdrawal? a. Within 8 to 12 hours of the client's last drink. b. 12 hours after admission. c. As blood pressure becomes elevated. d. When hand tremors are visible.

A Early alcohol withdrawal can begin as early as 4 to 6 hours after substance use is stopped. (B) Alcohol withdrawal can begin in 12 hours, but the nurse should be prepared to begin assessment sooner than 12 hours. (C) The client may have other symptoms of withdrawal before blood pressure becomes elevated. (D) The client may have other symptoms of withdrawal before hand tremors are visible.

Which nursing intervention is most important to implement before disulfiram therapy? a. Obtain the client's written consent to comply with facility protocol. b. Ensure that the client will not have access to alcohol after discharge from the hospital. c. Determine the longest period of sobriety and need for abstinence. d. Help the client identify triggers leading to possible alcohol abuse.

A Informed consent must be obtained to receive disulfiram therapy, or documentation can be noted in the chart that education was given about potential serious complications that can occur if client does not abstain from drinking. (B) Although the client should abstain from alcohol, his access to alcohol after discharge is out of the nurse's control. (C) There is no need to determine length of sobriety and need for abstinence. The client only needs to be motivated to comply with therapy. (D) This is not the most important intervention, but it can help the client identify better ways of coping with potential stressors.

Which is the most important consideration for discharge planning? a. Resources available to the client after discharge. b. Client's knowledge of the ongoing disease process. c. Longest period of sobriety and potential for relapse. d. Participation with Alcoholics Anonymous (AA) for abstinence.

A The most important consideration is the availability of resources to the client after discharge. These resources can include counseling with significant others, group therapy, and self-help programs like Alcoholics Anonymous. (B) Knowledge of the disease process can enhance the client's ability to maintain sobriety and stay motivated to change behaviors, but it is not the most important consideration for discharge planning. (C) The longest period of sobriety can provide evidence of past success or failure, but it is not the most important consideration for discharge planning. (D) There are many modalities available to clients for discharge planning, although AA is the most common group.

Which question should the nurse ask the client in order to determine whether the client is able to return to a precrisis level of functioning? a. "Do you have a support system and people who can help you?" b. "How have you successfully handled past crises?" c. "Why do you always feel so sad?" d. "What are some of your strengths?"

A The nurse must determine if the client has an adequate support system. (B) This question is best for the assessment phase of the crisis to identify coping mechanisms, specifically strengths and previous coping ability. (C) This is not a therapeutic question that invites insight into the client's level of functioning. (D) This question is appropriate for the assessment phase and is the first step of crisis intervention.

Which assessment is most important for safe alcohol detoxification? a. Vital signs at least every 4 hours. b. Type of alcohol ingested. c. Amount and last use of alcohol. d. History of delirium tremens (DTs).

A Vital signs are an objective measure of alcohol withdrawal, especially when the diastolic blood pressure, pulse, and temperature are near or above 100. (B) The type of alcohol ingested will be assessed on admission, but is not the priority during alcohol detoxification. (C) Assessing the amount and last use of alcohol is part of the admission assessment and will help determine the onset of withdrawal symptoms. (D) Assessing history of DTs is part of the admission assessment and will help determine the likelihood of DTs during detoxification.

What is the rationale for giving thiamine (B1) and a multivitamin? a. Reduce the risk of Wernicke disease. b. Prevent occurrence of delirium tremens. c. Lessen alcohol withdrawal symptoms. d. Help increase the client's appetite.

A Vitamin B deficiency is common in clients diagnosed with alcoholism. The small intestine is a major site of alcohol absorption, which interferes with adequate thiamine and all B vitamin absorption. Vitamin B deficiency can cause Wernicke disease. (B) Thiamine and a multivitamin will not prevent delirium tremens or alcohol withdrawal syndrome. (C) Thiamine and a multivitamin will not lessen alcohol withdrawal symptoms. (D) Increasing the client's appetite is not the rationale for giving thiamine and a multivitamin.

What are the ramifications of drinking alcohol while taking disulfiram? (Select all that apply.) a. Severe headache. b. Nausea and vomiting. c. Hypertension. d. Chest pain. e. Hypotension.

A, B, D, E A severe headache is one of the unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Nausea and vomiting are unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Chest pain is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Hypotension is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. (C) Hypertension is not a consequence of taking disulfiram.

Which behaviors of the client's partner exhibit codependency toward the client? (Select all that apply.) a. The client's partner states that moving out of their home caused the client to start drinking heavily. b. The client's partner removed hidden alcohol from the home and is now moving back to keep a close eye on the client. c. The client's partner brings two new pairs of jeans because the client only had one pair. d. The client's partner states they would like to have a child together. e. The client's partner paid all of the bills for the next two months so that the client won't have to worry about finances when discharged.

A, B, E Finding excuses for alcohol abuse is considered codependent behavior. The client's partner feels responsible for the client. Searching for and removing alcohol from the home is further evidence of codependent behavior. This shows that the client's partner feels a need to control the finances and assume responsibility for the client's duties. (C) This is unrelated to the drinking issue and does not demonstrate codependent behavior. (D) This does not demonstrate codependent tendencies.

Which items can the nurse allow the client to keep in the room? (Select all that apply.) Select all that apply a. Tennis shoes without laces. b. Aftershave lotion. c. Electronic book reader. d. An electronic cigarette. e. A personal photo.

A, C, E Tennis shoes without laces do not typically pose a threat. The client may keep an electronic book reader, but it cannot connect to the internet. The client must keep the battery's charging cord at the nurse's desk and the staff will charge the battery when needed. Personal photos do not pose a threat and may help the client feel more comfortable in the environment. (B) Aftershave lotion contains alcohol, and this is contraindicated for the client. (D) All cigarettes, including e-cigarettes, must be kept at the nurse's desk to ensure that the client doesn't try to smoke in the hospital.

Which products are acceptable for the client to use? (Select all that apply.) a. Ibuprofen. b. Mouthwash. c. Hand sanitizer. d. Petroleum jelly. e. Nonalcoholic beer.

A, D Ibuprofen is a nonsteroidal antiinflammatory medication used to treat fever and mild to severe pain. It does not contain alcohol and is safe for the client to use. Petroleum jelly does not contain alcohol, so it is safe for the client to use. (B) Most mouthwashes contain alcohol and should be avoided by the client. (C) Most hand sanitizers contains alcohol and should be avoided by the client. Any topical items containing alcohol should be avoided. (E) At times, nonalcoholic beer contains a small amount of alcohol and should be avoided by the client.

A client is accompanied to the emergency department (ED) by a police officer who found him standing on a bridge, threatening to jump. The client planned to jump off the bridge because significant other moved out of their shared home and the client lost their job as a chef several days ago. The client has a strong odor of alcohol on their breath, but reports drinking only four beers in the last 12 hours. The client denies using medications or illegal drugs within the past 72 hours. The client is known to the nursing staff because of previous admissions related to alcohol abuse. The client is angry and uncooperative, and the nurses will not allow the client to leave. The client states that they have felt sad for several weeks, which is the reason for drinking alcohol. The client reports sleeping 5 to 6 hours a night and states that their appetite is poor, resulting in significant weight loss over the past month. Physical health problems include a history of compromised liver function.

Assessment A simple tool the nurse can use to screen for alcoholism is the CAGE questionnaire. CAGE is an acronym that represents the four questions it contains.

Which response by the nurse is accurate? a. Disulfiram decreases cravings for alcohol. b. Disulfiram inhibits absorption of alcohol. c. Disulfiram blocks the effects of endorphins. d. Disulfiram prevents the client from drinking.

B Disulfiram inhibits the absorption of alcohol and raises the level of acetaldehyde, causing a severe reaction when alcohol is ingested. (A) Disulfiram does not decrease the cravings for alcohol. Medications such as naltrexone decrease cravings during the early stages of abstinence. (C) Disulfiram does not block the effects of endorphins. (D) Disulfiram cannot prevent someone who is determined to drink from drinking, but it can curtail impulsive drinking. The client should not drink until 14 days after disulfiram has been discontinued.

Which lab results indicate to the nurse the client likely has liver disease? a. Hyperkalemia. b. Increased aspartate aminotransferase (AST). c. Reduced alkaline phosphatase. d. Decreased blood urea nitrogen (BUN).

B Liver disease can cause a change in tissues of the liver and result in an elevation of AST. The amount of AST in the blood is directly related to the number of damaged cells. (A) Hypokalemia, rather than hyperkalemia, occurs in alcoholism due to urinary excretion of potassium. (C) Alkaline phosphatase is elevated, not reduced, in liver disease. The blood level of alkaline phosphatase rises when excretion is impaired as a result of obstruction in the biliary tract. (D) Increased, not decreased, BUN occurs with alcoholism.

What action should the nurse take next? a. Prepare the client for possible alcohol withdrawal. b. Further assess the client's drinking behaviors. c. Obtain blood alcohol content with a breathalyzer. d. Obtain a urine drug screen for polysubstance use.

B The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore, further assessment is needed to make a diagnosis of alcoholism. (A) The CAGE questionnaire is a screening tool that is used to identify individuals who may be abusing alcohol. The nurse needs more information to determine if the client has an alcohol addiction. (C) A breathalyzer is a screening tool used to determine recent alcohol use. The CAGE questionnaire is used as a screening tool for alcohol abuse. The nurse needs more information to determine if the client has an alcohol addiction. (D) A urine drug screen is a tool for alcohol or drug use. While this screening may become necessary to determine if the client is using other drugs, the nurse needs more information to determine if the client has an alcohol addiction.

Which goal is most important for alcohol detoxification? a. Discontinued drug-seeking behaviors. b. Physiological stabilization. c. Normal liver function test results. d. Enhanced coping skills.

B The acute management goals of alcohol detoxification begin with stabilizing the client physically and maintaining normal vital signs. (A) The judicious use of prescribed medications enables the client to safely detox, so it is not necessary to eliminate the use of all medications at this point in the client's treatment. (C) Liver function tests can be ordered by the healthcare provider to monitor for the extent of liver damage, but it is not the most important goal for the first 72 hours of alcohol detoxification. (D) Enhancing coping skills can only occur when the client is able to focus on the psychological work related to addiction, lifestyle changes, and alternatives for coping. This is a later goal in the plan of care.

If it is determined the client is dependent on alcohol, which information should the nurse obtain in order to predict the onset of withdrawal symptoms? a. The frequency with which the client drinks alcohol. b. The last time the client consumed an alcoholic beverage. c. The quantity of alcohol the client usually drinks. d. Past withdrawal symptoms the client has experienced.

B This can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 6 to 8 hours after alcohol use. (A) With increased frequency of alcohol consumption, tolerance is likely to develop, resulting in withdrawal symptoms. By itself, frequency of drinking is not a good predictor of the onset of withdrawal. (C) This will not help the nurse predict the onset of withdrawal symptoms. The client is likely to use denial, so a good rule of thumb is to double the amount of reported intake. (D) The client's previous withdrawal experiences will not predict the onset of the current withdrawal symptoms. If the client has experienced withdrawal in the past, it can help identify how the client will experience current symptoms.

Which interventions should the nurse implement? (Select all that apply.) a. Ask the primary HCP if the client can receive a prescription for chlordiazepoxide. b. Administer lorazepam 2 mg PO. c. Reassess vital signs in 2 hours. d. Place the client on a continuous pulse oximetry monitor. e. Provide an antiemetic.

B, C, E The client has compromised liver function; therefore, a short-acting benzodiazepine such as lorazepam is best to give for withdrawal because it does not have active metabolites that can affect a diseased liver. Lorazepam is often given if a client has known liver disease or decreased liver function. The nurse can reassess the vital signs to monitor for changes. The client reports feeling nauseous, so administering an antiemetic is advised. (A) The client's liver function test results are high. Normal AST is between 5 to 40 U/L (0.08 to 0.67 ukat/L), and normal ALT is between 7 to 56 units/L (0.12 to 0.94 ukat/L). Since the client has a compromised liver function, a benzodiazepine such as chlordiazepoxide with active metabolites should not be given because it can adversely affect a diseased liver. (D)The client's respirations are within normal range and there is no evidence of respiratory compromise.

Which priority nursing problem should be addressed within 72 hours of admission? (Select all that apply.) a. Ineffective denial. b. Risk for injury. c. Ineffective coping. d. Altered nutrition. e. Risk for withdrawal.

B, D, E Risk for injury related to the client's thoughts of wanting to jump off a bridge is a priority nursing problem and the rationale for admission to the crisis unit. A client with alcohol dependency drinks alcohol instead of eating nourishing food, causing malabsorption of essential vitamins. Deficiency and malabsorption of vitamin B can cause Wernicke's disease, a severe problem with decreased cognitive functioning. Alcohol withdrawal can occur as early as 4 to 6 hours after the client's last drink. (A) The client's denial is a defense mechanism that reduces anxiety. According to Maslow's hierarchy, it is not a priority. (C) Ineffective coping is a problem related to inadequate coping skills, but another nursing problem should be addressed first.

Which should the nurse anticipate if the client experiences symptoms of early withdrawal from alcohol? a. Mild disorientation and confusion. b. Tactile or auditory hallucinations. c. Tremors, nausea, and vomiting. d. Sleeping more than usual.

C In addition to tremors, nausea, and vomiting, other symptoms of early withdrawal include elevated vital signs, diaphoresis, insomnia, combativeness, agitation, and decreased concentration. (A) Disorientation and confusion occur with severe withdrawal. (B) Hallucinations generally occur after early withdrawal. (D) Clients who experience early withdrawal have insomnia.

Which action should the nurse take? a. Document that the initial client teaching was completed by the UAP. b. Praise the UAP for taking the initiative to complete higher priority tasks. c. Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse. d. Request that the UAP be assigned to another unit.

C Initial client teaching requires the expertise of the nurse. (A) The nurse must complete initial client teaching, so teaching must be repeated and documented as performed by the nurse. (B) The nurse must complete initial client teaching, which requires expertise beyond the level of a UAP. (D) This is not necessary at this time.

Which routine admission prescriptions should the nurse question? a. A regular diet. b. Vital signs every 4 hours. c. Acetaminophen as needed. d. Urinalysis and urine drug screen.

C The client is suspected of having liver problems due to alcohol. Acetaminophen can be toxic to the liver, especially in combination with alcohol. The nurse should question this prescription as it is contraindicated for the client. (A) A regular diet is appropriate for the client. (B) Vital signs every 4 hours is routine and applicable. (D) This is a routine admission prescription and is appropriate for the client.

Who should the nurse ask to complete the adverse event report? a. The nurse should complete the full report. b. The client should complete as much of the form as he is able. c. The technician helping at the time of the accident needs to complete the report. d. The nurse and the HCP should write the account of the incident for the report.

C The nurse should ask the technician to complete the report because the technician witnessed the client's fall. (A) This is not the best person to complete the report. (B) A staff member is responsible for completing the report. (D) The nurse should notify the HCP, but it is not necessary for the HCP to complete the report.

What is the first question that the nurse should ask? a. "Have people annoyed you by criticizing your drinking?" b. "Have you ever felt bad or guilty about your drinking?" c. "Have you ever thought that you should cut down on your drinking?" d. "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?"

C This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior. When sober, an alcoholic may make a pledge to reduce consumption. (A) This is the second question of the questionnaire. In CAGE, A stands for annoyed. Often the behaviors of alcoholics, especially when inebriated, are annoying to family and friends. Frequently the alcoholic is unaware of the behavior and is angered when family and/or friends complain. (B) This is the third question of the questionnaire. In CAGE, G stands for guilty. When sober, alcoholics often experience feelings of embarrassment and guilt about behavior that occurred while intoxicated. (D) This is the fourth question in the questionnaire. In CAGE, E stands for eye-opener. Eye-opener is a term used to describe the need to drink alcohol as soon as waking up to ward off or try to eliminate a hangover. It is a serious indication of overconsumption.

Which data supports the need for admission to the hospital? a. Drinking alcohol and potential withdrawal. b. Ineffective denial about severity of problem. c. Elevated vital signs and liver disease. d. Thoughts of wanting to jump off a bridge.

D The client is at risk for self-harm, which is a priority problem that requires hospitalization. (A) Drinking alcohol and potential withdrawal do not justify the need for hospitalization unless medical complications are anticipated. (B) Ineffective denial is a common defense mechanism that often occurs with substance use and does not warrant hospitalization. (C) Elevated vital signs and liver disease do not support the need for immediate hospitalization unless there are acute medical complications.