Alcoholism - Case Study - NRSG347
The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-AR) is a 10-item scale that monitors a client's response to treatment. It is a tool that determines the need for medication and can be used for management of alcohol withdrawal. Without effective management of alcohol withdrawal, the client can experience seizures or alcohol withdrawal delirium, which is characterized by impairment of memory, attention, thinking, perception, and orientation. What mechanism of action accounts for symptoms of alcohol withdrawal delirium? a) Increased dopamine b) Increased GABA c) Decreased norepinphrine d) Increased serotonin
Increased dopamine (Alcohol intake represses GABA, which inhibits dopamine and keeps dopamine levels low. When alcohol is eliminated, dopamine rebounds above the normal level, resulting in excitation and alterations in thought, perception, and orientation)
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)
Vital signs at least every 4 hours (Vital signs are an objective measure of alcohol withdrawal, especially when the diastolic blood pressure, pulse, and temperature are near or above 100)
Addiction treatments and interventions for maintenance are generally based on the idea of addiction as a disease, abstinence from all alcohol substances, participation in a 12-step program such as Alcoholics Anonymous (AA), and confrontation of denial and other defense mechanisms. After two weeks of hospitalization, Matt has detoxed from alcohol and denies current thoughts of suicidal ideation. The nurse knows that Matt experienced a situational crisis, and the goal is for him to return to a precrisis level of functioning. Which question should the nurse ask Matt in order to determine whether or not he is able to return to a precrisis level of functioning? a) "Do you have support 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 previous strengths?"
"Do you have support and people who can help you?" (The nurse must determine if the client has adequate support systems)
A simple tool the nurse can use to screen for alcoholism is the CAGE questionnaire. CAGE is an acronym that represents four questions it contains. What is the first question that the nurse should ask Matt? 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?"
"Have you ever thought that you should cut down on your drinking?" (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.)
Eight hours after Matt's admission, a new nurse is assigned to care for Matt. After receiving report, the nurse reviews the recent information in the chart. Vital Signs -BP 146/98 mmHg -HR 100 beats/min -R 22 breaths/min -T 99.8 degrees F Laboratory Data -AST: 80 units/L -ALT: 96 units/L -Na+: 145 -K+: 3.6 Prescriptions -1) Perform withdrawal assessment every 4 hours -2) Lorazepam (Ativan) 2 mg PO every 6 hours PRN per alcohol withdrawal protocol -3) Continue suicide precautions The nurse performs the withdrawal assessment and observes that Matt has moderate tremors and that he reports nausea Which intervention(s) should the nurse implement (Select all that apply) a) Ask the primary HCP if Matt can receive a prescription for chlordiazepoxide (Librium) b) Administer lorazepam (Ativan) 2 mg PO c) Reassess vital signs in 2 hours d) Place Matt on a continuous pulse oximetry monitor e) Provide an antiemetic
-Administer lorazepam (Ativan) 2 mg PO (Matt has compromised liver function; therefore, a short-acting benzodiazepine such as lorazepam (Ativan) is best to give for withdrawal because it does not have active metabolites that can affect a diseased liver. Lorazepam (Ativan) is often given if a client has known liver disease or decreased liver function) -Reassess vital signs in 2 hours (The nurse can reassess the vital signs to monitor for changes) -Provide an antiemetic (Matt reports feeling nauseous, so administering an antiemetic is advised)
While the nurse explains the potential consequences of drinking alcohol while taking disulfram (Antabuse), the nurse also discusses household products containing alcohol that should be avoided, such as cough medicines and aftershave lotion. Which product(s) are acceptable for Matt to use? (Select all that apply) a) Ibuprofen (Motrin) b) Mouthwash c) Hand sanitizer d) Petroleum jelly e) Non-alcoholic beer
-Ibuprofen (Motrin) (Ibuprofen (Motrin) is a nonsteroidal anti-inflammatory 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 (Petroleum jelly does not contain alcohol, so it is safe for the client to use)
What priority nursing diagnoses 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
-Risk for injury (Risk for injury related to Matt's thoughts of wanting to jump off a bridge is a priority nursing diagnosis and the rationale for admission to the crisis unit) -Altered nutrition (Nutrition is very important because 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 decrease cognitive functioning). -Risk for withdrawal (Alcohol withdrawal can occur as early as 4 to 6 hours after the client's last drink)
What are some of the ramifications of drinking alcohol while taking disulfiram (Antabuse)? (Select all that apply) a) Severe headache b) Nausea and vomiting c) Hypertension d) Chest pain e) Hypotension
-Severe headache (A severe headache is one of the unpleasant consequences of drinking alcohol while taking an aldehyde dehydrogenase inhibitor such as disulfram (Antabuse)). -Nausea and vomiting (Nausea and vomiting are unpleasant consequences of drinking alcohol while taking an aldehyde dehydrogenase inhibitor such as disulfram (Antabuse)). -Chest pain (Chest pain is an unpleasant consequence of drinking alcohol while taking an aldehyde dehydrogenase inhibitor such as disulfram (Antabuse)). -Hypotension (Hypotension is an unpleasant consequence of drinking alcohol while taking an aldehyde dehydrogenase inhibitor such as disulfram (Antabuse))
After the nurse and the UAP discuss the client teaching, the UAP expresses concerns with the nurse about Matt's girlfriend's visitation that took place earlier that day. Which of the girlfriend's behaviors exhibit codependency toward the client? (Select all that apply) a) The girlfriend states that moving out of their shared home caused the client to start drinking heavily b) The girlfriend tells the client she removed the hidden alcohol from the home and she is moving back in to keep a close eye on him c) She brings the client two new pairs of jeans because he only had one pair with him d) She tells the client that she is pregnant and is considering an abortion e) The girlfriend states she has paid all of the bills and has paid the client's rent for the next two months so that he won't have to worry about finances when he is discharged
-The girlfriend states that moving out of their shared home caused the client to start drinking heavily (Finding excuses for the alcohol abuse is a codependent behavior) -The girlfriend tells the client she removed the hidden alcohol from the home and she is moving back in to keep a close eye on him. (This behavior demonstrates that the girlfriend feels responsible for the client. Searching for and removing alcohol is further evidence of codependent behavior) -The girlfriend states she has paid all of the bills and has paid the client's rent for the next two months so that he won't have to worry about finances when he is discharged (This statement shows that the girlfriend feels a need to control the finances and assume responsibility for the client's duties, such as paying monthly rent)
When Matt is admitted to the Crisis Unit, the nurse understands that it is best to maintain a quiet, calm environment to help him relax and decrease nervous system irritability. The nurse must assign a room and search his belongings. Which items can the nurse allow Matt to keep in his room? (Select all that apply.) a) Unlaced tennis shoes b) Aftershave lotion c) Electronic book reader d) An electronic cigarette e) A personal photo
-Unlaced tennis shoes (Matt can keep his tennis shoes. Tennis shoes without laces do not typically pose a threat) -Electronic book reader (The client may keep his 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 may charge the battery for him as needed.) -A personal photo (Matt can keep a personal photo. This does not pose a threat and may help him feel more comfortable in his environment)
Routine admission prescriptions include regular diet, nutrition consultation, vital signs every 4 hours, CBC with differential, urinalysis, and urine drug screen. The HCP also prescribes acetaminophen (Tylenol) 325 mg PO every 6 hours PRN for pain, fever, or headache. Which routine admission prescriptions does the nurse question? a) A regular diet b) Vital signs every 4 hours c) Acetaminophen as needed d) Urinalysis and urine drug screen
Acetaminophen as needed (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 this client.)
After 3 days in the Crisis Stabilization Unit, Matt exhibits no further withdrawal symptoms. The nurse collaborates with the social worker and the HCP to determine discharge plans. Matt wants to return to his job as soon as possible. He describes his work as being a trigger for his drinking and he asks the nurse what he can do to prevent a relapse. Which response by the nurse is accurate? a) Disulfram (Antabuse) decreases cravings for alcohol b) Disulfram (Antabuse) inhibits absorption of alcohol c) Disulfram (Antabuse) blocks the effects of endorphins d) Disulfram (Antabuse) prevents the client from drinking
Disulfram (Antabuse) inhibits absorption of alcohol (Disulfram (Antabuse) inhibits the absorption of alcohol and raises the level of acetaldehyde, causing a severe reaction when alcohol is ingested)
The nurse enters Matt's room to assess his readiness for teaching related to local 12-step programs and observes that the Unlicensed Assistive Personnel (UAP) is already providing Matt with information about local programs. What 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
Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse (Initial client teaching requires the expertise of the nurse)
Matt answers "yes" to two of the four questions on the CAGE questionnaire. 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
Further assess the client's drinking behaviors (The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore, further assessment is needed to make a diagnosis of alcoholism)
Which lab results indicate to the nurse that Matt probably has liver disease? a) Hyperkalemia b) Increased aspartate aminotransferase (AST) c) Reduced alkaline phosphatase d) Decreased uric acid
Increased aspartate aminotransferase (AST) (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)
Which nursing intervention is most important to implement before Matt starts disulfram (Antabuse) therapy? a) Obtain Matt's written consent to comply with instructions b) Ensure that Matt will not have access to alcohol after discharge from the hospital c) Determine the longest period of sobriety and need for abstinence d) Help Matt identify triggers leading to possible alcohol abuse
Obtain Matt's written consent to comply with instructions (Informed consent must be obtained, and the client must sign consent to receive disulfram (Antabuse) therapy)
The nurse must follow the alcohol detoxification protocol. Which goal is most important for alcohol detoxification? a) Discontinued drug-seeking behaviors b) Physiologic stabilization c) Normal liver function test results d) Enhanced coping skills
Physiologic stabilization (The goals of acute management of alcohol detoxification begin with stabilizing the client physically and maintaining normal vital signs)
On the second day of Matt's hospitalization, the nurse prepares to give Matt thiamine and a multivitamin. Magnesium chloride (Slow Mag) is also prescribed to enhance the effectiveness of the thiamine. What is the rationale for giving thiamine (B1) and a multivitamin? a) Reduce the risk of Wernicke's disease b) Prevent occurrence of delirium tremens c) Lessen alcohol withdrawal symptoms d) Help increase the client's appetite
Reduce the risk of Wernicke's disease (Vitamin B deficiency is common in clients diagnosed with alcoholism. A major site of alcohol absorption is the small intestine, which interferes with adequate thiamine and all B vitamin absorption. Vitamin B deficiency can cause Wernicke's disease)
The nurse collaborates with the treatment team to make plans for discharge. What 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 relapse d) Acceptance of AA for abstinence
Resources available to the client after discharge (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 groups such as AA)
A mental health technician arrives to help Matt take a shower. The technician gathers towels and belongings, then helps Matt to the shower. As Matt opens the door to the bathroom and steps inside the door, he slips and falls on the floor. The technician reports the incident to the nurse. The nurse assesses Matt, and Matt denies hitting his head or suffering any other injuries. The nurse documents the assessment, which includes a full set of vital signs, and then notifies the HCP. The nurse knows that an incident (variance) report must be completed). Who should the nurse ask to complete the incident report? a) The nurse should complete the full report b) Matt should complete as much of the form as he is able c) The technician helping Matt at the time of his accident needs to complete the report d) The nurse and the HCP should write the accounts of the incident for the report
The technician helping Matt at the time of his accident needs to complete the report (The nurse should ask the technician to complete the report because since the technician witnessed the client's fall)
The nurse completes the assessment and reports the findings to the healthcare provider (HCP). The HCP talks with Matt and decides to admit him to the crisis unit with an admitting diagnosis of alcohol dependency and depression with suicidal ideation. What 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) Thought of wanting to jump off a bridge
Thought of wanting to jump off a bridge (The client is at risk for self-harm because he has thoughts of jumping off a bridge. Risk for self-harm is a priority problem that requires hospitalization)
What should the nurse anticipate if Matt 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
Tremors, nausea, and vomiting (In addition to tremors, nausea, and vomiting, other symptoms of early withdrawal include elevated vital signs, diaphoresis, insomnia, combativeness, agitation, and decreased concentration)
When should the nurse begin assessing for withdrawal? a) Within 4 to 6 hours of the client's last drink b) 12 hours after admission c) As blood pressure becomes elevated d) When hand tremors are visible
Within 4 to 6 hours of the client's last drink (Early alcohol withdrawal can begin as early as 4 to 6 hours after substance use is stopped)
The nurse gives Matt a benzodiazepine for withdrawal symptoms and an antiemetic for nausea What is the therapeutic action of benzodiazepines? a) Potentiate effects of GABA b) Block reuptake of dopamine c) Block reuptake of serotonin d) Activate opioid receptors
Potentiate effects of GABA (Benzodiazepines potentiate the effects of GABA, which has a calming effect)
If it is determined that Matt 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
The last time the client consumed an alcoholic beverage (This information is important, and the answer can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 4 to 6 hours after substance use)
