Psych Exam 4: Substance Abuse, Violence, Impulse Control Disorders

7. During which phase of alcoholism is loss of control and physiologic dependence evident? A. Prealcoholic phase B. Early alcoholic phase C. Crucial phase D. Chronic phase

7. C. Crucial phase**Rationale: The crucial phase is marked by physical dependence. The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration.

2. In a toddler, which of the following injuries is most likely the result of child abuse? A. A hematoma on the occipital region of the head B. A 1-inch forehead laceration C. Several small, dime-sized circular burns on the child's back D. A small isolated bruise on the right lower extremity

2. C. Several small, dime-sized circular burns on the child's back**Rationale: Small circular burns on a child's back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.

20. Which of the following signs should the nurse expect in a client with known amphetamine overdose? A. Hypotension B. Tachycardia C. Hot, dry skin D. Constricted pupils

20. B. Tachycardia**Rationale: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

28. Which is the drug of choice for treating Tourette syndrome? A. fluoxetine (Prozac) B. fluvoxamine (Luvox) C. haloperidol (Haldol) D. paroxetine (Paxil)

28. C. haloperidol (Haldol)** Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome

37. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. begin after 7 days. B. not occur at all because the time period for their occurrence has passed. C. begin anytime within the next 1 to 2 days. D. begin within 2 to 7 days.

37. C. begin anytime within the next 1 to 2 days. **Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.

40. Which assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mm Hg D. Blood pressure of 140/80 mm Hg

40. A. Heart rate of 120 to 140 beats/minute**Rationale: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

43. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use. B. The student accepts a referral to a substance abuse counselor. C. The student agrees to inform his parents of the problem. D. The student reports increased comfort with making choices.

43. B. The student accepts a referral to a substance abuse counselor.**Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

44. A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the physician is most likely to prescribe which drug? A. clozapine (Clozaril) B. thiothixene (Navane) C. lorazepam (Ativan) D. lithium carbonate (Eskalith)

44. C. lorazepam (Ativan)** Rationale: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.

45. A client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

45. A. Al-Anon**Rationale: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve-step program.

50. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is: A. psychotherapy. B. total abstinence. C. Alcoholics Anonymous (AA). D. aversion therapy.

50. B. total abstinence. **Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.

**57. A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"

57. B. "You told me you got fired from your last job for missing too many days after taking drugs all night." **Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.

61. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry

61. B. Calling a security guard and another staff member for assistance**Rationale: The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.

65. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

65. B. Aftershave lotion**Rationale: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client.

67. Victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization

67. B. Readiness to leave the perpetrator and knowledge of resources**Rationale: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships.

68. A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2 % (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. acetate accumulation. B. thiamine deficiency. C. triglyceride buildup. D. a below-normal serum potassium level

68. B. thiamine deficiency.**Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms.

75. Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal

75. C. Opiate withdrawal**Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.

77. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond: A. "You must first stop drinking." B. "Your physician must refer you to this program." C. "Admit you're powerless over alcohol and that you need help." D. "You must bring along a friend who will support you."

77. C. "Admit you're powerless over alcohol and that you need help."**Rationale: The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a support person who may be called upon when the client has the urge to drink.

79. After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future? A. "I'm never going to use crack again." B. "I know what I have to do. I have to limit my crack use." C. "I'm going to take 1 day at a time. I'm not making any promises." D. "I will substitue crack for something else"

79. C. "I'm going to take 1 day at a time. I'm not making any promises." **Rationale: Twelve-step programs focus on recovery 1 day at a time. Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limited amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the client to cross-addiction.

84. A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? A. Alcohol withdrawal B. Cannibis withdrawal C. Cocaine withdrawal D. Opioid withdrawal

84. D. Opioid withdrawal**Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

86. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: A. tension and irritability. B. slow pulse. C. hypotension. D. constipation.

86. A. tension and irritability.**Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.

24. Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder? A. An overbearing mother B. Rejection by peers C. A history of schizophrenia in the family D. Low socioeconomic status

24. B. Rejection by peers**Rationale: Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Aggression and conduct disorder are represented in all socioeconomic groups. Schizophrenia and an overbearing mother haven't been associated with aggression or conduct disorder

11. A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations? A. A no-suicide contract B. Weekly outpatient therapy C. A second psychiatric opinion D. Intensive inpatient treatment

11. D. Intensive inpatient treatment **Rationale: Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-suicide contract is an important strategy, but this client requires additional care. Weekly therapy wouldn't provide the intensity of care that this case warrants. Obtaining a second opinion would take time; this client requires immediate intervention.

12. Which of the following etiologic factors predispose a client to Tourette syndrome? A. No known etiology B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics C. Abnormalities in the structure and function of the ventricles D. Environmental factors and birth-related trauma

12. B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics**Rationale: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucleus. The ventricles in the brain, environmental factors, and birth trauma aren't involved.

13. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using? A. Withdrawal B. Logical thinking C. Repression D. Denial

13. D. Denial **Rationale: Denial is an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking IS the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.

14. An 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include: A. violence on television. B. passive parents. C. an internal locus of control. D. a single-parent family

14. A. violence on television. **Rationale: Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence.

15. A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands that: A. open boundaries are common in violent families. B. violence usually results from a power struggle. C. domestic violence and abuse span all socioeconomic classes. D. violent behavior is a genetic trait passed from one generation to the next.

15. C. domestic violence and abuse span all socioeconomic classes. **Rationale: Domestic violence and abuse affect all socioeconomic classes. Closed boundaries and an imbalance of power, with one member having control over the others, are common in violent families. Although violent behavior may be passed from one generation to the next, it's a learned behavior, not a genetic trait.**

16. On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to: A. avoid all products containing alcohol. B. adhere to concomitant vitamin B therapy. C. return for monthly blood drug level monitoring. D. limit alcohol consumption to a moderate level.

16. A. avoid all products containing alcohol. **Rationale: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy and blood monitoring aren't necessary during disulfiram therapy.

17. During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response? A. "That's it! You're on suicide precautions." B. "I'm going to tell your physician. Do you want to tell me why you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection." D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

17. D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." **Rationale: This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. Options A and B put the client on the defensive and may lead to a power struggle. Option C ignores the psychological implications of the client's actions.

18. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: A. barbiturates. B. amphetamines. C. methadone. D. benzodiazepines.

18. C. methadone. **Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.

19. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include: A. dilated pupils and slurred speech. B. rapid speech and agitation. C. dilated pupils and agitation. D. euphoria and constricted pupils.

19. D. euphoria and constricted pupils. **Rationale: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.

21. A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode

21. A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output**Rationale: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care. Fluids are typically increased unless contraindicated by a preexisting medical condition.

22. Which nursing action is best when trying to diffuse a client's impending violent behavior? A. Helping the client identify and express feelings of anxiety and anger B. Involving the client in a quiet activity to divert attention C. Leaving the client alone until the client can talk about feelings D. Placing the client in seclusion

22. A. Helping the client identify and express feelings of anxiety and anger**Rationale: In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as "What happened to get you this angry?" may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of the client acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and provides a feeling of security.

23. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client? A. Abstinence is the basis for successful treatment. B. Attendance at Alcoholics Anonymous meetings every day will cure alcoholism. C. For treatment to be successful, family members must participate. D. An occasional social drink is acceptable behavior for the alcoholic

23. A. Abstinence is the basis for successful treatment.**Rationale: The foundation of any treatment for alcoholism is abstinence. Attendance at Alcoholics Anonymous is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking.

25. In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using? A. Denial B. Obsession C. Compensation D. Rationalization

25. A. Denial**Rationale: A client who states that he or she doesn't have a drug problem and can quit using drugs at any time — despite evidence to the contrary — is denying the drug addiction. Obsession isn't a defense mechanism. In compensation, the client emphasizes positive attributes to compensate for negative ones. In rationalization, the client justifies behaviors by faulty logic.

29. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting." a

29. B. "Tell me how you feel about the accident."**Rationale: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency.

30. A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

30. D. Diaphoresis, tremors, and nervousness**Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.

31. When monitoring a client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. norepinephrine (Levophed) and lidocaine (Xylocaine). B. nifedipine (Procardia) and lidocaine. C. nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc). D. nifedipine and esmolol

31. D. nifedipine and esmolol**Rationale: This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an antiarrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension.

32. A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle. B. The client will work with the nurse to remain safe. C. The client will drink plenty of fluids daily. D. The client will make a personal inventory of strengths

32. B. The client will work with the nurse to remain safe. **Rationale: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

33. A client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hypervigilance and talk of past violent acts

33. A. A rigid posture, restlessness, and glaring**Rationale: Behavioral clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance.

34. A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

34. D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."**Rationale: According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A), increased time and money spent on the substance (option B), inability to fulfill role obligations (option C), and typical withdrawal symptoms.

39. A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes

39. C. Providing a quiet environment and administering medication as needed and prescribed**Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.

48. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband: A. has only moderate impulse control. B. denies feelings of jealousy or possessiveness. C. has learned violence as an acceptable behavior. D. feels secure in his relationship with his wife.

48. C. has learned violence as an acceptable behavior. **Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.

5. A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response? A. "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?" B. "It's your decision. If you don't want to go, you don't have to." C. "You seem upset about the meetings." D. "You have to go to the meetings. It's part of your treatment plan."

5. C. "You seem upset about the meetings."** Rationale: The substance abuser uses the substance to cope with feelings and may deny the abuse. Asking if the client is upset about the meetings encourages the client to identify and deal with feelings instead of covering them up. Arguing with the client about the substance abuse (option A) or insisting that the client attend the meetings (option D) wouldn't help the client identify resistance to treatment. Option B isn't therapeutic behavior because it plays down the importance of attending meetings.

51. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain

51. A. Seizures**Rationale: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

54. Which of the following drugs should the nurse prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. deferoxamine mesylate (Desferal) B. succimer (Chemet) C. flumazenil (Romazicon) D. acetylcysteine (Mucomyst)

54. D. acetylcysteine (Mucomyst)**Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.

55. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium)

55. D. chlordiazepoxide (Librium)**Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

59. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age. B. The mother and father tell different stories regarding what happened. C. The family is poor. D. The parents are argumentative and demanding with emergency department personnel.

59. A. The injury isn't consistent with the history or the child's age.**Rationale: When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child.

6. A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written: A. abstractly. B. by the client alone. C. jointly by the client and nurse. D. jointly by the physician and nurse.

6. C. jointly by the client and nurse. **Rationale: A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior. The most effective contract — and the type least likely to allow for manipulation and misinterpretation — states the behavioral terms as concretely as possible. A contract written solely by the client may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client.

63. The nurse is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergyperson to discuss the moral implications of suicide

63. B. Exploring the nurse's own feelings about suicide**Rationale: The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn't a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may increase the client's trust or alleviate guilt; however, it isn't the highest priority.

69. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination. B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined. D. The child doesn't make eye contact with the nurse.

69. C. The child doesn't cry when the shoulder is examined.**Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers.

70. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Client's psychosocial needs D. Client's medical needs

70. B. Client's safety needs**Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client's physical, psychosocial, and medical needs can be met.

71. Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. Accept responsibility for own behaviors. B. Be able to verbalize own needs and assert rights. C. Set firm and consistent limits with the client. D. Allow the child to establish his own limits and boundaries.

71A. Accept responsibility for own behaviors. **Rationale: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.

74. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect: A. a postoperative infection. B. alcohol withdrawal. C. acute sepsis. D. pneumonia.

74. B. alcohol withdrawal. **Rationale: The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.

8. Which of the following is important when restraining a violent client? A. Have three staff members present, one for each side of the body and one for the head. B. Always tie restraints to side rails. C. Have an organized, efficient team approach after the decision is made to restrain the client. D. Secure restraints to the gurney with knots to prevent escape.

8. C. Have an organized, efficient team approach after the decision is made to restrain the client. **Rationale: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots

80. The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to: A. accurately describe the amount consumed. B. underestimate the amount consumed. C. overestimate the amount consumed. D. deny any consumption of alcohol.

80. B. underestimate the amount consumed. **Rationale: Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves. Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.

82. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is: A. impending coma. B. manipulating behavior. C. suppression. D. perceptual disorders.

82. D. perceptual disorders.**Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but aren't signs of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.

87. Which of the following drugs may be abused because of tolerance and physiologic dependence. A. lithium (Lithobid) and divalproex (Depakote). B. verapamil (Calan) and chlorpromazine (Thorazine) C. alprazolam (Xanax) and phenobarbital (Luminal) D. clozapine (Clozaril) and amitriptyline (Elavil)

87C. alprazolam (Xanax) and phenobarbital (Luminal)**Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.

89. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as: A. echolalia. B. palilalia. C. apraxia. D. aphonia.

89. B. palilalia.**Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak

9. A client who's actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP? A. Dilated pupils B. Nystagmus C. Paranoia D. Altered mood

9. B. Nystagmus**Rationale: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus and ataxia are common physical findings of PCP use. Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood occur with both PCP and LSD ingestion.