Chapter 6

Low risk response in SMAST-G is ?

0-1 points

What is a standard drink of spirits?

1.5 oz

SMAST-G is composed of how many questions with what kind or responses?

10 / Yes & No

What is a standard drink of beer?

12 oz

What answers will equal a AUDIT score 3?

2-3 a week 7 - 9 Weekly

What answers will equal a AUDIT score 2?

2-4 times a month 5 or 6 monthly yes, but not in the last year

What is a standard drink of martinis?

3 oz

What is a standard drink of fortified wine?

3-4 oz

How many questions are in the CAGE Test?

4

What answers will equal a AUDIT score 4?

4 or more a week 10 or more Daily or almost daily Yes, during the last year

What is a standard drink of table wine?

5 oz

What is a standard drink of malt liquor?

9-8 oz

Scoring 2 or more "Yes" responses on SMAST-G indicates what?

A indication of a drinking problem.

Scores 0 to 9 indicate what on CIWA of alcohol?

Absent or minimal withdrawl

Mean corpuscular volume (MCV) is?

An index of red blood cell size The size increases when alcohol is present.

How are the point values divided in TWEAK?

Answering "yes" to T & W = 2 points Answering "yes" to questions E, A, & K = 1 point

The nurse is caring for a 55-year-old patient who has diabetes and a habit of drinking a maximum of 2 alcoholic drinks per day. What risk does the nurse expect in the patient? Nephritis Neurosis Cardiomyopathy Atrial fibrillation

Atrial fibrillation

Mean corpuscular volume (MCV) is not sensitive enough to do what?

Be a only bio marker for drinking problems

The nurse uses the Clinical Institute Withdrawal Assessment (CIWA) for a patient who is undergoing withdrawal therapy for alcohol abuse. The nurse checks for tactile disturbances in the patient by asking, "Do you feel like bugs are crawling on your skin?" The nurse gives a score of 7 after the assessment. Which finding in the patient led the nurse to give such score? Severe hallucinations Continuous hallucinations Extreme severe hallucinations Moderately severe hallucinations

Continuous hallucinations Why?: A score of 7 indicates that the patient has continuous hallucinations.

CAGE test stands for?

Cut down Annoyed Gulity Eye-Opener

What is the CAGE Test not good for?

Distinguishing past problems of drinking May not detect low, but risky, problems in women & minorities

What is the most commonly used biomarker of alcohol drinking?

GGT

Occasional alcohol drinking does not raise what? What does raise this?

GGT levels Chronic alcohol drinking

Non-alcoholic liver diease can raise what?

GGT levels in absence of alcohol

How many "Yes"es in a CAGE test signals possible alcohol abuse?

Greater than or equal to 2.

How many questions signals a drinking problem in TWEAK?

Greater than or equal to 2.

The health care provider asks the nurse to stop monitoring the blood pressure, pulse, respirations, and oxygen saturation in an alcohol-abusing patient based on the rating of Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). What is the reason for the health care provider's decision? The patient's total score on CIWA-Ar is less than 8 for 72 hours. The patient's total score on CIWA-Ar is less than 12 for 72 hours. The patient's total score on CIWA-Ar is more than 11 for72 hours. The patient's total score on CIWA-Ar is more than 15 for 72 hours.

If the total CIWA-Ar score is less than 8 for 72 hours, the nurse can stop monitoring; this score indicates the patient is retaining his or her original physical condition.

CDT & GGT work together to do what?

Increase detection of alcohol abuse

The nurse is caring for an alcoholic patient who has been drinking 50 grams of alcohol per day for 1 week. What does the nurse expect to find in the patient's laboratory data? Increased mean corpuscular volume (MCV) Increased gamma glutamyl transferase (GGT) Increased carbohydrate deficient transferrin (CDT) Increased serum aspartate aminotransferase (AST)

Increased carbohydrate deficient transferrin (CDT) Why?: Elevation of CDT occurs in patients who drink 50 to 80 grams of alcohol per day for at least 1 week.

The nurse is caring for a patient with a history of cannabis abuse who is reported to have reddened eyes, dry mouth, and tachycardia. What behaviors does the nurse expect in the patient? Jittery feeling Slurred speech Impaired memory Increased perceptions Social withdrawal

Increased perceptions Social withdrawal

The patient who is admitted in the rehabilitation facility center for opioid abuse stops taking opioids abruptly. Which signs would the nurse find in the patient? Lacrimation Tachycardia Hypersomnia Pinpoint pupils Decreased blood pressure

Lacrimation Tachycardia

What long does it take to complete a CAGE test?

Less than a minute. *Works well in busy enviroments

While assessing the laboratory reports of a patient, the nurse finds an increase in the level of gamma glutamyl transferase (GGT). Which conditions does the nurse identify as potential causes for increased levels of GGT? Liver disease Alcohol relapse Alcohol abstinence Chronic alcohol drinking Occasional alcohol drinking

Liver disease Alcohol relapse Chronic alcohol drinking

The nurse is caring for a 70-year-old patient with a history of alcohol abuse. What health problems does the nurse expect to find in the patient? Employment problems Liver problems Pneumonia Kidney problems Gastrointestinal problems

Liver problems Kidney problems Gastrointestinal problems

Scores 10 to1 9 indicate what on CIWA of alcohol?

Mild-to-moderate withdrawl

What answers will equal a AUDIT score 1?

Monthly or less 3 to 4 Less than monthly

What answers will equal a AUDIT score 0?

Never 1 or 2 No

SMAST-G is a questionnaire for ?

Older Adults

A patient has undergone outpatient treatment for alcohol use disorder. At a 6-month check-in the patient reports lingering cravings for alcohol, but no symptoms of withdrawal, and no instances of drinking since starting treatment. The patient also reports difficulty in meeting new friends who do not drink alcohol. How should the nurse document the patient's current status? Patient is in early remission Patient is in sustained remission Patient has mild severity alcohol use disorder Patient has moderate severity alcohol use disorder

Patient is in early remission

Scores greater than or equal to 20 indicate what on CIWA of alcohol?

Severe withdrawl

The nurse observes paroxysmal sweats in a patient who has alcohol withdrawal symptoms, and gives a score of 4 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). What is the reason for the nurse to give this score? The patient has no visible sweating. The patient has sweat drops on the forehead. The patient is completely wet due to sweating. The patient has barely perceptible sweating but has moist palms.

The patient has sweat drops on the forehead.

The laboratory test results of a patient who abuses alcohol show increased levels of the enzyme serum aspartate aminotransferase (AST). What does the nurse infer from this finding? The patient is a heavy drinker. The patient is a chronic drinker. The patient is a moderate drinker. The patient is an occasional drinker.

The patient is a chronic drinker.

While assessing an agitated alcoholic patient, the nurse gives a score of 7 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA Ar). What could be the reason for this score? The patient has a normal activity. The patient is moderately fidgety. The patient has somewhat normal activity. The patient paces back and forth most of the time.

The patient paces back and forth most of the time. Why?:An alcoholic patient appears unsteady due to loss of coordination. A score of 7 during the agitation assessment indicates that the patient paces back and forth during most of it.

CIWA of alcohol measures what?

The progress of withdrawls

TWEAK stands for?

Tolerance Worry Eye-Opener Amnesia Kut Down

Which sign is associated with sympathetic system stimulation due to alcohol? Hypoactivity Hypotension Vasodilation Vasoconstriction

Vasoconstriction Why?: Intake of alcohol has a stimulatory effect on the sympathetic nervous system, and even moderate alcohol intake can cause vasoconstriction.

TWEAK identifies risk in who?

Women