Behavior 211 T4 Questions from Varc ch 22/Sims & Saunders

Intoxication: Opioids

Constricted pupils Decreased Respirations Drowsiness Euphoria Hypotension Impairment of Memory, Attention, and Judgement Psychomotor Retardation Slurred Speech

Cocaine, when snorted, may result in which route-related complication? A. Nasal septum damage B. Nasal polyps C. Chronic nasal congestion D. Nasal dryness

A Rationale: A common route for the ingestion of cocaine is nasal "snorting." After repeated use, the drug can cause damage to the nasal mucosa and nasal septum.

The provision of optimal care for patients withdrawing from substances of abuse is facilitated by the nurse's understanding that severe morbidity and mortality are often associated with withdrawal from: a. Alcohol and CNS depressants. b. CNS stimulants and hallucinogens. c. Narcotic antagonists and caffeine. d. Opiates and inhalants.

A

A client was in an automobile accident and while there is the odor of alcohol on his breath, his speech is clear, and he is alert and answers questions posed to him. His blood alcohol level is determined to be 0.30 mg%. What conclusion can be drawn? A. The client has a high tolerance to alcohol. B. The client ate a high-fat meal before drinking. C. The client has a decreased tolerance to alcohol. D. The client's blood alcohol level is within legal limits.

A Rationale: A nontolerant drinker would evidence staggering, ataxia, confusion, and stupor at this blood alcohol level.

The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group if the nurse hears the wife make which statement? A. "I no longer feel that I deserve the beatings my husband inflicts on me." B. "My attendance at the meetings has helped me to see that I provoke my husband's violence." C. "I enjoy attending meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."

A Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option 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.

A client who is dependent on alcohol tells the nurse, "Alcohol is no problem for me. I can quit anytime I want to." The nurse can assess this statement as indicating A. denial. B. projection. C. rationalization. D. reaction formation.

A Rationale: Believing that one can control drug use, despite addiction to the substance, is based on denial

A nurse is assessing Tyler Morgan to determine the frequency of his drug use. When asked about the frequency of drug use, he reports that he sometimes uses drugs, but not nearly as much as some of the other kids at school. This report is an example of: A. devaluation. B. denial. C. idealization. D. splitting.

A Rationale: Devaluation results when an individual attributes negative attitudes or characteristics to another to make himself look better.

A nurse is preparing a care plan for a patient recently admitted to the mental health unit. The nurse demonstrates knowledge of the nursing process when writing which nursing diagnosis? A. Ineffective coping related to depressed mood as evidenced by sleeplessness and fatigue B. Risk for injury related to ineffective coping C. Pain as evidenced by complaints of pain level at 8/10 and nonverbal cues D. Ineffective coping and risk for injury related to recent loss of spouse as evidenced by statements of not wanting to "go on" without spouse

A Rationale: Ineffective coping related to depressed mood as evidenced by sleeplessness and fatigue is an actual, rather than potential nursing diagnosis and contains all three parts of the nursing diagnosis: the problem, the risk factors or cause/s of the problem, and the defining characteristics that support the problem. The other options do not include all of the proper components.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want anymore treatment. I have things that I have to go do right away." The client has not been discharged and 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. What action should the nurse take? A. Call the nursing supervisor B. Call security to block all exit areas C. Restrain the client until the health care provider can be reached D. Tell the client that the client cannot return to this hospital again if the client leaves now

A Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and the sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

Which assessment data would be most consistent with a severe opiate overdose? A. Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min B. Blood pressure, 120/80 mm Hg; pulse, 84 beats/min; respirations, 20 breaths/min C. Blood pressure, 140/90 mm Hg; pulse, 76 beats/min; respirations, 24 breaths/min D. Blood pressure, 180/100 mm Hg; pulse, 72 beats/min; respirations, 28 breaths/min

A Rationale: Opiate overdose results in lowered blood pressure with a rise in pulse rate along with respiratory depression.

Which statement demonstrates the use of the therapeutic communication technique of restating? "You say that you don't think your parents understand you at all?" "It sounds as though you don't think your parents listen to you." "Let me see if I understand what you are saying. You feel you are misunderstood?" "Can you describe how you feel when you talk to your parents?"

A Rationale: Restating involves repeating what the patient has said in order to ensure understanding and review what the patient has stated. Option A demonstrates restating. Options B and C demonstrate clarification. Option D is questioning the patient in order to gain more insight or knowledge.

Symptoms that would signal opioid withdrawal include A. lacrimation, rhinorrhea, dilated pupils, and muscle aches. B. illusions, disorientation, tachycardia, and tremors. C. fatigue, lethargy, sleepiness, and convulsions. D. synesthesia, depersonalization, and hallucinations.

A Rationale: Symptoms of opioid withdrawal resemble the "flu"; they include runny nose, tearing, diaphoresis, muscle aches, cramps, chills, and fever.

When providing care to Tyler Morgan, which assessment is of the highest priority? A. Assessing for risk of suicide B. Assessing hours of sleep he has had over the past 24 hours C. Assessing dietary intake D. Assessing elimination processes over the past 4 days

A Rationale: The assessments listed will all be included in the plan of care. However, it is most important for the nurse to determine the risk for suicide or self harm.

A nurse is reviewing the nursing care plan initiated by the nurse who completed the admission assessment for Tyler Morgan. When the nurse is planning care for the shift, which nursing diagnosis is of the highest priority? A. Risk for suicide B. Anxiety C. Ineffective coping D. Ineffective impulse control

A Rationale: The individual who has an addiction to cocaine may have each of the presented nursing diagnoses. However, the risk for suicide is the highest priority. Tyler Morgan is also experiencing manifestations consistent with depression, again highlighting the potential of suicide risk.

The treatment team meets to discuss Cody's plan of care. Which of the following factors will be priorities when planning interventions? A. Readiness to change and support system B. Current college performance C. Financial ability D. Availability of immediate family to come to meetings

A Rationale: The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual's cultural needs. The other options may be factors but are not the priority factors in planning interventions for the patient as much as the patient's perceived need for change and having others who can lend support outside the hospital.

When should the nurse introduce the termination phase of the nurse-patient relationship to the patient? A. During the orientation phase B. During the working phase C. At the beginning of the termination phase D. Towards the end of the termination phase

A Rationale: The termination phase should be introduced during the orientation phase, much like discharge planning during an admission in a medical-surgical setting. This allows for the patient and nurse to make plans for discharge, and lets the patient know there are limits to the nurse-patient relationship.

When caring for Tyler Morgan, which nursing action is of the highest priority? A. Establishing a trusting relationship B. Providing teaching about the impact of cocaine use on the body C. Encouraging small, frequent meals D. Assisting with grooming as needed

A Rationale: Tyler Morgan would benefit from all of the nursing interventions listed. The need for Tyler to be able to establish a trusting relationship would allow for the other therapies to have the greatest benefit.

Nursing assessment of an alcohol-dependent client 6 to 12 hours after the last drink would most likely reveal the presence of A. tremors. B. seizures. C. blackouts. D. hallucinations.

A Rationale: Tremors are an early sign of alcohol withdrawal.

The only class of commonly abused drugs that has a specific antidote is the A. opiates. B. hallucinogens. C. amphetamines. D. benzodiazepines.

A Rationale: The effects of opiates can be negated by a narcotic antagonist such as naloxone.

What should the nurse expect to occur if the working phase of the nurse-patient relationship is successful? Select all that apply. A. A change In patient behavior B. The patient develops effective problem-solving skills C. Maintaining of rapport between the nurse and the patient D. Dependency of the patient on the nurse for support E. The patient is able to recognize his or her problems

A, B, C, D Rationale: Although the nurse should be supportive of the patient, the patient should not be dependent on the nurse for support. Independence is what the nurse wants to instill in the patient. Changes in behavior, developing problem-solving skills, developing rapport with the patient, and the patient recognizing his or her own problems are all desirable outcomes.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? SELECT ALL that apply A. Monitor vital signs B. Maintain NPO status C. Provide a safe environment D. Address hallucinations therapeutically E. Provide stimulation in the environment F. Provide reality orientation as appropriate

A, C, D, F Rationale: When the client is experiencing withdrawal from alcohol, the priority of care is to prevent the client from harming self 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 sign closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

Manifestations of Alcohol Withdrawal Delirium

Agitation Anorexia Anxiety Delirium Diaphoresis Disorientation with fluctuating levels of consciousness Fever (Temp 100-103) Hallucinations and Dillusions Insomnia Tachycardia and Hypertension

Intoxication: Hallucinogens

Agitation and Belligerence Anxiety and Depression Bizarre, Regressive, or Violent behaviors Blank Stare Diaphoresis Dilated Pupils Elevated v/s including BP Hallucinations Impairment of judgement and social and occupational functioning Incoordination Muscular rigidity and chronic jerking Paranoia Seizures Tachycardia Tremors

Early signs of Alcohol Withdrawal

Anorexia Anxiety Easily Startled Hyper-alertness Hypertension Insomnia Irritability Jerky movements Possibly experience hallucinations, illusions, delusions, or vivid nightmares Possibly reports a feeling of "shaking inside" Seizures (usually appear 7 to 48 hours after cessation of alcohol) Tachycardia Tremors

You are caring for Mick, a 32-year-old patient with chemical addiction who will soon be preparing for discharge. A principle of counseling interventions that should be observed when caring for a patient with chemical addiction is to: a. Praise the patient for compliant behavior. b. Communicate that relapses are always possible. c. Confirm that the patient's recovery is considered complete after discharge. d. Encourage Mick to resume his former friendships to regain a sense of normalcy.

B

The nurse forms a contract with the patient during which stage of the nurse-patient relationship? a. Pre-orientation stage B. Orientation stage C. Working stage D. Termination stage

B Rationale: A contract is formed during the orientation stage. It may be informal or formal, and it addresses meeting times, plans, and expectations that the patient is held accountable for. The pre-orientation stage occurs prior to meeting the patient. The working stage is when the nurse and patient are actively working toward a patient goal and the patient has accepted responsibilities. The termination stage is when the nurse-patient relationship is coming to an end.

A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive, and the staff is having difficulty keeping him and themselves safe. The nursing intervention that would be most therapeutic is A. taking him to the gym on the psychiatric unit. B. obtaining an order for seclusion and close observation. C. assigning a psychiatric technician to "talk him down." D. administering naltrexone as needed per hospital protocol.

B Rationale: Aggressive, violent behavior is often seen with PCP ingestion. The client will respond best to a safe, low-stimulus environment such as that provided by seclusion until the effects of the drug wear off. Talking down is never advised because of the client's unpredictable violent potential. Naltrexone is an opiate antagonist.

A person who covertly supports the substance-abusing behavior of another is called a(n) A. patsy. B. enabler. C. participant. D. minimizer.

B Rationale: An enabler is one who helps a substance-abusing client avoid facing the consequences of drug

Cocaine exerts which of the following effects on a client? A. Stimulation after 15 to 20 minutes B. Stimulation and anesthetic effects C. Immediate imbalance of emotions D. Paranoia

B Rationale: Cocaine exerts two main effects on the body, both anesthetic and stimulant.

A nurse is completing the intervention portion of a nursing care plan for a patient on the mental health unit. Which should the nurse use as a guide for choosing interventions? A. Nursing care plan references B. Evidence-based practice guidelines C. Previous experience D. Physician's orders

B Rationale: Evidence-based practice interventions should be utilized whenever possible since these interventions have been tested and scientifically proven. This allows the best care to be given. Nursing care plan references and previous experience may not always have the most current evidenced-based practice interventions. Physician's orders often address the medical diagnosis more closely than the nursing diagnosis.

Cody is a 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months. He is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for Cody's treatment plan while in the hospital? A. Cody will return to a predrug level of functioning within 1 week. B. Cody will be medically stabilized while in the hospital. C. Cody will state within 3 days that he will totally abstain from drugs and alcohol. D. Cody will take a leave of absence from college to alleviate stress.

B Rationale: If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge. The first option is an unrealistic time frame. It is not likely that the patient will make a total commitment to abstinence within this time frame. Although a leave of absence may be an option, the immediate need is to make sure the patient goes through drug and alcohol withdrawal safely.

When speaking with Tyler Morgan concerning his cocaine use, he reports that he cannot see what the big deal is. When questioned further, he reports that "everyone else in his class at school is using the drug as well." Which defense mechanism does this most closely represent? A. Denial B. Projection C. Realization D. Rationalization

B Rationale: Projection is a defense mechanism that allows the individual to reject emotionally unacceptable personal features and attributes to other people. Denial is refers to the escape of unpleasant realities by ignoring their existence. Rationalization involves attempts to justify actions.

A young woman reports that although she has no memory of the event, she believes that she was raped. This raises suspicion that she unknowingly ingested A. LAAM B. GHB C. ReVia D. Clonidine

B Rationale: The drugs most frequently used to facilitate a sexual assault (rape) are flunitrazepam (Rohypnol, "roofies"), a fast-acting benzodiazepine, and gamma-hydroxybutyrate (GHB) and its congeners. These drugs are odorless, tasteless, and colorless; mix easily with drinks; and can render a person unconscious in a matter of minutes. Perpetrators use these drugs because they rapidly produce disinhibition and relaxation of voluntary muscles; they also cause the victim to have lasting anterograde amnesia for events that occur.

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? A. "Why don't you tell your wife about this?" B. "What do you find difficult about this situation?" C. "This is not the best time to make that decision." D. " I agree with you, you should get out of this situation."

B Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.

Erik is a 26-year-old patient who abuses heroin. He states to you, "I've been using more heroin lately. I told my provider about it and she said I need more and more heroin to feel the effect I want." You know this describes: A. intoxication. B. tolerance. C. withdrawal. D. addiction.

B Rationale: Tolerance is described as needing increasing greater amounts of a substance to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect. Intoxication is the effect of the drug. Withdrawal is a set of symptoms patients experience when they stop taking the drug. Addiction is loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? A. Ask the client why he started taking illegal drugs B. Ask the client about the amount of drug use and its effects C. Ask the client how long he thought he could take drugs without someone finding out. D. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home

B Rationale: Whenever the nurse carries out an assessment for 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 and off-focus, and reflects the nurse's bias. Option 3 is incorrect b/c it is judgmental, insensitive, and aggressive, which is non-therapeutic. Option 4 is incorrect b/c it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

Tyler Morgan's medical history reveals excessive sleeping, depression, reduced dietary intake, and cocaine use. Which nursing intervention is of the highest importance in the initial period after hospitalization? A. Providing a quiet environment to promote rest when he desires B. Encouraging small, frequent meals C. Encouraging participation in interaction with the nurse D. Enrollment in group therapy for substance abusers

B Rationale: During the initial period of hospitalization, it is most important that Tyler Morgan be able to establish an interactional relationship with the nurse.

1. When intervening with a patient who is intoxicated from alcohol, it is useful to first: a. Let the patient sober up. b. Decide immediately on care goals. c. Ask what drugs other than alcohol the patient has recently used. d. Gain adherence by sharing your personal drinking habits with the patient.

C

An appropriate long-term goal/outcome for a recovering substance abuser would be that the client will A. discuss the addiction with significant others. B. state an intention to stop using illegal substances. C. abstain from the use of mood-altering substances. D. substitute a less addicting drug for the present drug.

C Rationale: Abstinence is a highly desirable long-term goal/outcome. It is a better outcome than short-term goal because lapses are common in the short term.

In helping an addicted individual plan for ongoing treatment, which intervention is the first priority for a safe recovery? A. Ongoing support from at least two family members must be secured. B. The client needs to be employed. C. The client must strive to maintain abstinence. D. A regular schedule of appointments with a primary care provider must be set up.

C Rationale: Abstinence is the safest treatment goal for all addicts. Abstinence is strongly related to good work adjustments, positive health status, comfortable interpersonal relationships, and general social stability.

Which statement demonstrates the therapeutic communication technique of focusing? A. "Tell me more about your job." B. "It sounds like you are very unhappy with your work situation right now. Is this correct?" C. "You have mentioned several things. Let's go back to your relationships with your co-workers." D. "I can relate to how you feel. My co-workers don't seem to care about their job or how anyone feels."

C Rationale: Focusing allows the nurse to converge on the most important points of a conversation, discussion, or interview. Option A demonstrates the therapeutic technique of using a broad statement. Option B demonstrates the therapeutic technique of clarifying. Option D is a non-therapeutic technique because the nurse is focusing on her own feelings.

The most helpful message to transmit about relapse to the recovering alcoholic client is that lapses A. are an indicator of treatment failure. B. are caused by physiological changes. C. result from lack of good situational support. D. can be learning situations to prolong sobriety.

C Rationale: Relapses can point out problems to be resolved and can result in renewed efforts for change

A teaching need is revealed when a client taking disulfiram (Antabuse) states, A. "I usually treat heartburn with antacids." B. "I take ibuprofen or acetaminophen for headache." C. "Most over-the-counter cough syrups are safe for me to use." D. "I have had to give up using aftershave lotion."

C Rationale: The client taking disulfiram has to avoid hidden sources of alcohol. Many cough syrups contain alcohol.

The Psychiatric Mental Health Nursing Standards of Practice are based on what professional activity that the nurse performs when providing care to the patient? A. The QSEN model B. State nurse practice acts C. The nursing process D. NCLEX state board examination

C Rationale: The nursing process is a problem-solving method of providing nursing care and is used in all nursing settings. QSEN is the acronym for quality and safety education for nurses. The goal of QSEN is to prepare future nurses to provide safe and high quality care. Each state has its own nurse practice acts which help guide nurses in providing care that is allowed in his or her scope of practice according to the nursing degree held. The NCLEX state board examination is the computerized test for licensure.

Tyler Morgan is admitted with a primary diagnosis of depression. During depressive episodes, the patient may not be participative in meeting self care needs. Which action by the nurse is most appropriate? A. Asking the nursing assistant to perform hygiene measures on him B. Requesting that Tyler's mother bathe him C. Encouraging Tyler to perform self care activities D. Allowing Tyler to wait until he feels up to performing self care activities

C Rationale: When planning the activities related to self care for individuals who are depressed, it may be necessary to provide assistance.

Which of the drugs used by a polysubstance abuser is most likely to be responsible for withdrawal symptoms requiring both medical intervention and nursing support? A. Opiates B. Marijuana C. Barbiturates D. Hallucinogens

C Rationale: Withdrawal from central nervous system depressants is complicated, requiring carefully titrated detoxification with a similar drug. Abrupt withdrawal can lead to death.

Which of the following is true regarding substance addiction and medical comorbidity? A. Most substance abusers do not have medical comorbidities. B. There has been little research done regarding substance addiction disorders and medical comorbidity. C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. D. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.

C Rationale: The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.

A syndrome that occurs after stopping the long-term use of a drug is called A. amnesia. B. tolerance. C. enabling. D withdrawal.

D

As you evaluate a patient's progress, which treatment outcome would indicate a poor general prognosis for long-term recovery from substance abuse? a. Patient demonstrates improved self-esteem. b. Patient demonstrates enhanced coping abilities. c. Patient demonstrates improved relationships with others. d. Patient demonstrates positive expectations for ongoing drug use.

D

The term tolerance, as it relates to substance abuse, refers to A. the use of a substance beyond acceptable societal norms. B. the additive effects achieved by taking two drugs with similar actions. C. the signs and symptoms that occur when an addictive substance is withheld. D. the need to take larger amounts of a substance to achieve the same effects.

D

You are caring for Leah, a 26-year-old patient who has been abusing CNS stimulants. Which statement provides a basis for planning care for a patient who abuses CNS stimulants? a. Symptoms of intoxication include dilation of the pupils, dryness of the oronasal cavity, and excessive motor activity. b. Medical management focuses on removing the drugs from the body. c. Withdrawal is simple and rarely complicated. d. Postwithdrawal symptoms include fatigue and depression.

D

Benzo's are useful for treating alcohol withdrawal because they? A. Block Cortisol Secretion B. Increase Dopamine Release C. Decrease Serotonin Release D. Exert a Calming Effect

D Rationale: Benzodiazepines act by binding to α-aminobutyric acid-benzodiazepine receptor sites, producing a calming effect.

What is the ethical obligation of the nurse who sees a peer divert a narcotic, compared with the ethical obligation when the nurse observes a peer who is under the influence of alcohol? A. The nurse should immediately report the peer who is diverting narcotics and should defer reporting the alcohol-using nurse until a second incident takes place. B. Neither should be reported until the nurse has collected factual evidence. C. No report should be made until suspicions are confirmed by a second staff member. D. Supervisory staff should be informed as soon as possible in both cases.

D Rationale: If indicators of impaired practice are observed, the observations need to be reported to the nurse manager. Intervention is the responsibility of the nurse manager and other nursing administrators. However, clear documentation (specific dates, times, events, consequences) by co-workers is crucial. The nurse manager's major concerns are with job performance and client safety. Reporting an impaired colleague is not easy, even though it is our responsibility. To not "see" what is going on, nurses may deny or rationalize, thus enabling the impaired nurse to potentially endanger lives while becoming sicker and more isolated. Impairment can occur whether the nurse is under the influence of alcohol or a narcotic drug.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypertension, coarse hand tremors, lethargy D. Hypertension, changes in level of consciousness, hallucinations

D Rationale: Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions

During the admission assessment of a patient to a mental health facility, the patient says to the nurse, "I need to share something with you, but you have to promise not to tell anyone." Which response is the best response by the nurse? A. "I want you to know that you can share anything with me." B. "I would rather wait until further into our session for you to share confidential information." C. "I must share information you give me with your immediate family members so that they are aware of important issues." D. "In order to provide you the best care, I will need to share this information with members of the health care team who are involved in your direct care."

D Rationale: The nurse is obligated to share information with the health care team in order to provide continuity of care. Misleading the patient would prevent the patient from trusting the nurse, thus blocking a therapeutic relationship. Confidentiality prevents the nurse from sharing information with immediate family members unless there is a legal reason to do so.

A nursing instructor is reviewing a care plan for a patient on the mental health unit that was written by a nursing student. Which outcomes identification statement demonstrates that the nursing student understands the nursing process? Patient demonstrates effective coping skills Patient will voice less feelings of anxiety Patient will understand the policies and rules within 3 days of admission Patient will remain free from injury during the entire stay on the mental health unit

D Rationale: The outcomes identification statement is a patient goal which should be measurable and specific. Option D is specific, contains a time frame, and is measurable. The other options are either vague or are not measurable.

When providing education to Tyler Morgan and his family, which statement concerning withdrawal and tolerance is most correct? A. Withdrawal and tolerance are terms that are correctly used interchangeably. B. Tolerance refers to the ability of the patient to use a substance without worry of painful withdrawal. C. Withdrawal of a substance refers to the psychological dependencies that result when a patient has developed increased tolerance to a substance. D. The symptoms of withdrawal are physical and result when a substance has not been ingested over a period of time.

D Rationale: Tolerance and withdrawal are different phenomena. Tolerance refers to an individual's need for increasing amounts/concentrations of a substance to achieve the same effects. Discontinuation of a substance may result in withdrawal. The symptoms may be psychological or physiological in nature.

A client has been using cocaine intranasally for 4 years. When brought to the hospital in an unconscious state, nursing measures should include A. induction of vomiting. B. administration of ammonium chloride. C. monitoring of opiate withdrawal symptoms. D. observation for hyperpyrexia and seizures.

D Rationale: Hyperpyrexia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose.

Cody is preparing for discharge. He tells you, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? A. "It helps your mood so that you don't feel the need to do drugs." B. "It will keep you from experiencing flashbacks." C. "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." D. "It helps prevent relapse by reducing drug cravings."

D Rationale: Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. The other options do not accurately describe the action of naltrexone.

Withdrawal Delirium is a Medical Emergency

Death can occur from myocardial infarction, fat emboli, peripheral vascular collapse, electrolyte imbalance, aspiration pneumonia, or suicide

Intoxication: Central Nervous System Stimulants

Dilated pupils Euphoria Hypertension Impairment of judgement and social or occupational functioning Insomnia Nausea and Vomiting Paranoia, Delusions, Hallucinations Potential for Violence Tachycardia

Inotxication: Central Nervous System Depressants

Drowsiness Hypotension Impairment of memory, attention, judgement, and social or occupational functioning Incoordination and unsteady gait Irritability Slurred speach

Intoxication: Inhalants

Enhancement of sexual pleasure Euphoria Excitation followed by drowsiness, lightheadedness, disinhibition, and agitation Giggling and laughter

Withdrawal: Nursing Care

Obtain info regarding the type of drug and amount consumed Assess Vital Signs Remove unnecessary objects from the environment Provide one-to-one supervision if necessary Provide a quiet, calm environment with minimal stimuli Maintain client orientation Ensure client's safety by implementing seizure precautions Use security devices if necessary and as prescribed to prevent client from harming self and others Provide for physical needs Provide food and fluids as tolerated Administer medications as prescribed to decrease withdrawal symptoms Collect blood and urine samples for drug screening

The nurse notes that a client is experiencing signs of alcohol withdrawal delirium. What should the nurse do?

The nurse should immediately contact the health care provider if signs of alcohol withdrawal delirium occur and the nurse should follow agency protocol using specified assessment scales. One-to-one supervision needs to be provided to ensure safety. The nurse should provide care in a nonjudgmental manner and monitor vital signs (every 15 minutes). The environment should be quiet and non stimulating, and a family member should be encouraged to stay with the client to minimize anxiety. The nurse should orient the client frequently, explain all treatments and procedures in a quiet and simple manner, initiate seizure precautions, and administer sedating or anticonvulsant medication as prescribed. In addition, the nurse should provide small, frequent, high-carbohydrate foods (administer anti-emetic before meals as needed)

Instruct the client who is on disulfiram (Antabuse) to avoid

The use of substances that contain alcohol, such as cough medicines, rubbing compounds, vinegar, mouthwashes, and aftershave lotions. The client needs to read the label of all products

Flashbacks

Unexpected reexperiences of the effects of taking a hallucinogenic drug, can occur for extended periods of time after its original use. Safety during flashbacks is a priority

Part of the assessment should include

they type of alcohol, how much, for how long, and when last consumed