Health and Illness Concepts: Maladaptive Behavior....Addiction Questions

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?" Rationale: Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement?

"I no longer feel that I deserve the beatings my husband inflicts on me." Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option 1 is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option 2). Option 3 indicates that the group is being seen as an escape, not a place to work on issues. Option 4 indicates that the wife remains codependent.

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?" Rationale: The most helpful response is "What aspects of this situation are the most difficult for you?" This response encourages the spouse to explore the problem and problem-solve. Option 2 disregards the spouse's concern and focuses instead on the reaction of the alcoholic client. The nurse needs to neither agree, as in option 4, nor disagree, as in option 1, with the spouse. Giving advice implies that the nurse knows what is best and can also foster dependency.

The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying." Rationale: The long-term prognosis for newborns with FAS is poor. Signs/symptoms of withdrawal include tremors, abnormal reflexes, sleeplessness, seizures, abdominal distention, hyperactivity, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. As a result of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or at the latest, within the first 3 days of life. Most newborns with FAS are mildly to severely cognitively impaired. The newborn is usually growth deficient at birth.

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply?

"Within a few hours" Rationale: Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon. Rationale: Al-Anon is a support group for families of alcoholics. Fresh Start is a self-help group for those with addiction to nicotine. Families Anonymous is a support group for parents of children who abuse substances. Alcoholics Anonymous is a major self-help organization for those who suffer from alcoholism.

The nurse is reviewing the health record of a client with laryngeal cancer. The nurse should expect to note which most common risk factor for this type of cancer documented in the record?

Cigarette Smoking. Rationale: The most common risk factor associated with laryngeal cancer is cigarette smoking. Alcohol abuse may have a synergistic effect with cigarette smoking. Air pollution is also a contributing cause as are chronic laryngitis and consistent voice strain.

The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia. Rationale: The signs/symptoms associated with opioid withdrawal are depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia. Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last consumed dose. The signs/symptoms identified in option 1 are associated with nicotine withdrawal. Option 2 describes alcohol withdrawal. Option 4 describes cocaine withdrawal. Option 3 identifies factors associated with opioid withdrawal.

The nurse is caring for a client who has been admitted for alcohol abuse and knows that which medications may be prescribed in the treatment of this disorder? Select all that apply.

Diazepam Disulfiram Chlordiazepoxide Rationale: Medications used in the treatment of alcohol abuse include diazepam, disulfiram, chlordiazepoxide, carbamazepine, acamprosate calcium, phenobarbital, quetiapine fumarate, and naltrexone. Bupropion is used in the treatment of nicotine addiction, and methadone hydrochloride is used in the treatment of opiate addiction.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms?

Hypertension, disorientation, hallucinations. Rationale: The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

A 50-year-old client with a history of cardiac disease has been admitted to the intensive care unit (ICU) with a diagnosis of acute alcohol withdrawal. Which initial client data should the nurse expect to find? Select all that apply.

Insomnia Diaphoresis Tachycardia Increased serum total bilirubin Rationale: Clients over 40 years of age with a history of cardiac disease who are experiencing acute alcohol withdrawal should be admitted to the cardiac care unit. They will exhibit irritability, agitation, anxiety and tremors, confusion, hallucinations, and delusions. Insomnia, diaphoresis, tachycardia, fever and seizures, and nausea and vomiting will also be present. Because of the history of alcoholism and related cirrhosis, an increased serum total bilirubin level is expected. Hypertension and not hypotension occurs, and because of associated liver damage, the ammonia level is increased and not decreased.

The nurse suspects that a coworker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

Report the information to a supervisor. Rationale: An impaired nurse is one who is unable to function effectively because of some type of substance abuse. Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor who will then report to the board of nursing. Options 1, 3, and 4 are incorrect. Confronting the nurse may cause a conflict. The supervisor will report the substance abuse situation as necessary.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? Dilated pupils, tachycardia, and diaphoresis Yawning, irritability, diaphoresis, cramps, and diarrhea Tachycardia, hypertension, sweating, and marked tremors Depressed feelings, high drug craving, fatigue, and agitation

Yawning, irritability, diaphoresis, cramps, and diarrhea. Rationale: Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 1 describes intoxication from hallucinogens. Option 3 describes withdrawal from alcohol. Option 4 describes withdrawal from cocaine.

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply.

The newborn is irritable. The newborn cries incessantly. The newborn is difficult to console. The newborn hyperextends and postures. Rationale: A newborn born to a woman using drugs is irritable and is easily overloaded by sensory stimulation. The newborn may cry incessantly and be difficult to console. The newborn would not be lethargic and would hyperextend and posture rather than cuddle when being held.

A client has been hospitalized and has participated in substance abuse therapy group sessions. The client has consented to participate in Alcoholics Anonymous (AA) community groups after discharge. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." Rationale: The statement by the client that best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use is "I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared." The client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in the statement. Option 1 indicates client denial. In option 4 the client is relying heavily on others. Finally in option 2 the client is concrete and procedure oriented; again, the client denies that "nothing will go wrong that way" if the client follows all the directions.

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement?

"What do you find difficult about this situation?" Rationale: The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations. =)

The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply.

Tremors Irritability Hypertension Exaggerated startle reflex Rationale: Clinical signs/symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

Alcoholics Anonymous. Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1: Al-Anon is a group for families of alcoholics. Option 2: Fresh Start is for nicotine addicts. Option 3: Families Anonymous is for parents of children who abuse substances.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?

Call the nursing supervisor. Rationale: The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (option 3) and cannot be told otherwise.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly. Rationale: A neonate born to a woman who is addicted to drugs is irritable, may cry incessantly, and be difficult to console. The neonate would hyperextend and posture rather than cuddle when being held.

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose?

Disulfiram. Rationale: Disulfiram is a medication used for alcoholism that aids in the maintenance of sobriety. An adverse reaction occurs if the client drinks while taking this medication. The client should be motivated to stop drinking before being given this medication. The other medications are incorrect. Pyridoxine, vitamin B6, is a vitamin supplement. Chlordiazepoxide is a benzodiazepine used to manage anxiety disorders and alcohol withdrawal symptoms. Clonidine is an antihypertensive and is also used in opioid withdrawal.

The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

History of substance abuse during this pregnancy. Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include low socioeconomic status, poor prenatal care and nutrition, and a history of substance abuse during pregnancy. Weight gain of 25 to 35 pounds is acceptable for a woman of average nonpregnant weight. Prenatal care beginning in the first trimester is not an added risk factor. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort. Rationale: Features associated with FAS include craniofacial abnormalities, cleft lip or palate, abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies, and increased respiratory effort during the transition to extrauterine life also are noted frequently in the neonate with FAS.

The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern. Rationale: A primary nursing goal for the neonate diagnosed with FAS is to establish nutritional balance following delivery. These neonates may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling also will help establish appropriate sleep/rest patterns in the neonate.

A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?

Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures. Rationale: The first trimester "organogenesis" is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this crucial period depend not only on the amount of alcohol consumed, but also on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman.

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Teaches about the effects of cocaine on the heart and offers referral for further help. To provide the most holistic care, the nurse should meet the information needs of the client about the effects of cocaine on the heart and offer referral for further help with this possible addiction. Option 1 is not indicated and breaches the client's right to confidentiality. Option 2 is partially correct but does not meet the holistic needs of the client. Option 3 is incorrect because it "preaches" to the client.

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?

When the last alcoholic drink was consumed. Rationale: Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?

✅Abnormal palmar creases. Rationale: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. =) Options 1, 3, and 4 " A length of 19 inches" "A birth weight of 6 pounds and 14 ounces" "A head circumference that is appropriate for gestational age".... Are NORMAL FINDINGS in the full-term newborn infant.

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license. Rationale: The DUI conviction resulting in a 1-year suspended license best supports the nurse's concern that the client is not using effective coping skills. This best reflects the nurse's concern because reliance on alcohol, especially to the degree that it results in serious illegal behavior, represents ineffective coping. Individuals diagnosed with borderline personality disorder may display self-destructive behaviors as a result of inadequate psychological resources. Although a 1½-pack-a-day nicotine habit indicates the use of nicotine as an unhealthy coping mechanism, it does not have the same degree of potential danger to both the client and innocent victims. Option 2, a two-year alienation from parents and siblings, and option 3, a weight loss of 10 pounds in the last 2 months, may be a result of factors other than ineffective coping.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?

Drug withdrawal. Rationale: Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased use of calories). This response and the signs and symptoms of drug withdrawal seem to be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular hemorrhage are characterized by symptoms of CNS depression.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?

✅Offer to take the client to an examination room until he or she can be treated. Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

The nurse is preparing to reinforce instructions to the client who has been given a prescription for diphenoxylate with atropine. Which instructions should the nurse include?

Do not exceed the recommended dose because it can be habit forming. Rationale: Diphenoxylate with atropine is an antidiarrheal, and the client should not exceed the recommended dose because it may be habit forming. Because it is an antidiarrheal, it should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness.

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse determines to include which essential elements in the discharge teaching guide? Select all that apply.

Avoid potentially hepatotoxic over-the-counter drugs. Teach symptoms of complications and when to seek prompt medical attention. Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting. Rationale: Because the liver is unable to metabolize many over-the-counter drugs it is important for the client to avoid these. The client and family must also know that cirrhosis of the liver is a chronic condition, and there are many associated complications that require immediate medical intervention. Because of the risk of hemorrhage, spicy food and activities that increase pressure within the portal system must be avoided.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids? Fever, yawning, irritability, diaphoresis, and diarrhea. Increased appetite, irritability, anxiety, and restlessness. Depressed feelings, high drug craving, fatigue, agitation, and disorientation. Tachycardia, mild hypertension, fever, sweating, nausea, vomiting, and marked tremors.

Fever, yawning, irritability, diaphoresis, and diarrhea. Rationale: Opioids are central nervous system (CNS) depressants. Fever, yawning, irritability, diaphoresis, and diarrhea identify some of the signs/symptoms associated with withdrawal from opioids. The signs/symptoms in option 2 characterize withdrawal from nicotine, whereas option 3 describes withdrawal from cocaine, and option 4 describes withdrawal from alcohol.

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate. Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.