Substance Abuse, Eating Disorders, Impulse Control Disorders Passpoint

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance Explanation: The nurse 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, nurse should inform the spouse what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the spouse to leave would probably be ineffective in the agitated and irrational state. Exploring the spouse's anger doesn't take precedence over safeguarding the client and staff.

A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication?

lorazepam Explanation: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Benzodiazepines are cross-dependent with alcohol and possess antianxiety and anticonvulsant properties. Both heightened anxiety and seizures are associated with alcohol withdrawal. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs are not used to manage alcohol withdrawal syndrome.

A client admitted to the alcohol detoxification program asks the nurse if there is a medication to "stop me from wanting a drink so badly." The nurse should teach the client about:

naltrexone. Explanation: Naltrexone is a drug that can decrease alcoholic cravings. Chlordiazepoxide and other sedatives help reduce the symptoms of alcohol withdrawal but don't decrease cravings. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?

seizures Explanation: 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.

A client is prescribed chlordiazepoxide as needed to control the symptoms of alcohol withdrawal. Which symptoms may indicate the need for an additional dose of this medication? Select all that apply.

tachycardia elevated blood pressure and temperature tremors increasing anxiety Explanation: Benzodiazepines such as chlordiazepoxide are usually administered based on elevations in heart rate, blood pressure, and temperature as well as on the presence of tremors and increasing anxiety. Mood swings are expected during the withdrawal period and aren't an indication for further medication administration. Piloerection isn't a symptom of alcohol withdrawal.

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:

tension and irritability. Explanation: Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea, not constipation, is a common adverse effect.

A client is prescribed clonidine to treat alcohol withdrawal. Which assessment data will the nurse monitor for?

hypotension Explanation: Clonidine is used as adjunctive therapy in opioid withdrawal. It is mainly used for the treatment of blood pressure, however. With treatment for alcohol withdrawal, a priority assessment should be for hypotension. Polyuria, numbness and tingling, and tremors are not common side effects of clonidine.

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, a nurse asks when the client had the last alcoholic drink. The client says that the last drink was 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to peak:

in 1 to 2 days. Explanation: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Alcohol withdrawal delirium may occur 2 to 4 days — even up to 7 days — after the last drink.