Health Assessment Ch. 6 Substance Abuse A.Q.
The nurse is assessing the extent of alcohol abuse in a patient by using the Alcohol Use Disorders Identification Test (AUDIT). The nurse asks the patient how often the patient has felt guilt or remorse after drinking in the last year. After listening to the answer, the nurse gives the score of 4. How did the patient answer? "I usually felt guilty once a week." "I felt guilty almost every day." "I felt guilty maybe once in a month." "I never had a feeling of guilt or remorse."
"I felt guilty almost every day." If the patient says that he or she feels guilty almost every day, the score given would be 4. If the patient feels guilty once a week, the nurse would give a score of 3. If the patient says that he or she feels guilty once a month, the nurse would give a score of 2. If the patient says that he never feels guilty for consuming alcohol, the nurse would give a score of 0. If the patient feels guilty less than once per month, then the score would be 1. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. p. 97
While assessing alcohol abuse in a patient using the Alcohol Use Disorders Identification Test (AUDIT), the nurse asks, "In the last year, how often have you needed a drink first thing the morning after a night of heavy drinking?" The patient responds and admits, "Maybe once a month." What AUDIT score should the nurse give to this patient? 1 2 3 4
2 According to the Alcohol Use Disorders Identification Test (AUDIT), if the patient answers that he or she may require a first drink in the morning once every month, the score given would be 2. If the patient requires a morning drink once in every 2 to 3 months, the score given would be 1. If the patient needs a morning drink once every week, the score given would be 3. The patient who requires a daily morning drink after a night of heavy drinking would be given a score of 4. p. 97
What is the approximate number of standard drinks present in a 22 oz bottle of a malt liquor? 1.5 2 2.5 4.5
2.5 A standard drink is defined as one that contains 14 grams of pure alcohol. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has defined the standard drinks for each type of container. A 22 oz bottle of malt liquor contains 2.5 standard drinks. A 12 oz bottle of malt liquor contains 1.5 standard drinks. A 16 oz bottle of malt liquor contains 2 standard drinks. A 40 oz bottle of malt liquor contains 4.5 standard drinks. p. 94
The nurse wants to assess a pregnant patient using the Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire. The patient answers yes to the questions pertaining to tolerance and eye-opener, but answers no for questions pertaining to worry, amnesia, and kut down. What is the patient's total score? Record your answer using a whole number.
3 The Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire is used to assess alcohol dependency in pregnant women, and the scoring is based on the patient's responses to each question. The test gives 2 points each for Tolerance and Worry and 1 each for Eye-opener, Amnesia, and Kut down questions. Since this patient answered yes for only the questions pertaining to Tolerance and Eye-opener, it indicates that the patient has a score of 3 (2+1) on the TWEAK questionnaire. pp. 98-99
What is the maximum score given on the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) to a patient who has alcohol withdrawal symptoms? 63 67 70 76
67 The various parameters assessed using CIWA-Ar are nausea and vomiting, tremors, tactile disturbances, auditory disturbances, paroxysmal sweats, anxiety, visual disturbances, agitation, headaches, and orientation/clouding of sensorium. For each of the above parameters, the total score is 7 except for orientation, for which the total score is 4. Therefore, the maximum score on the CIWA-Ar scale is 67 (63 + 4). p. 102
According to the survey conducted at the University of Michigan in 2012 by the National Institute of Drug Abuse (NIDA), which is the first most abused drug by 12th graders? Diazepam (Valium) Amphetamine (Adderall) Heroin (diacetylmorphine) Methylphenidate (Ritalin)
Amphetamine (Adderall) Amphetamine (Adderall) is the drug prescribed for attention deficit hyperactivity disorder (ADHD) in children, but teenagers are commonly known to abuse it. From the survey report of NIDA, it was noted that most of the 12th graders surveyed were addicted to amphetamines. Children also abuse methylphenidate, but that drug comes after amphetamine. Diazepam is a hypnotic drug, which is classified under benzodiazepines. Heroin is an opioid drug used as pain reliever. These drugs were not commonly abused by the 12th graders in the survey. p. 104
Which signs and symptoms may appear in a patient who is undergoing treatment for nicotine withdrawal? Anxiety Frustration Hallucinations Awakening at night Irregular heart beat
Anxiety Frustration Awakening at night The patient experiencing nicotine withdrawal may experience anxiety, frustration, anger, nervousness, irritability, restlessness, and awakening at night. Anxiety, frustration, and panic occur due to the effect of hormone rebalancing on brain functioning. The patient may awaken at night for a few months due to depression once there is an absence of nicotine. Hallucinations are not characteristic of nicotine withdrawal or nicotine abuse. Irregular heartbeat is observed in patients who continue drug abuse or experience an overdose of stimulants. p. 103
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 The National Institute on Alcohol Abuse and Alcoholism (NIAA) has categorized patients depending upon their gender and also based upon the amount of alcohol consumed. According to the NIAA, a person who drinks not more than 2 drinks per day is considered a moderate drinker. Generally, moderate drinkers are not at major risk, but this patient's age and diabetes diagnosis increase the patient's risk of atrial fibrillation. Nephritis may be observed in a patient who has diabetes mellitus for a long time. Alcohol may depress the central nervous system and may temporarily relieve neurosis. Patients who drink heavily are at risk of cardiomyopathy. p. 93
The nurse is educating a group of student nurses about diagnosis of substance abuse. The nurse explains that the test is used to determine lifetime alcohol abuse and dependence in a patient; it may not, however, be helpful in distinguishing past problem drinking from active present drinking. What test is the nurse teaching about? Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire Alcohol Use Disorders Identification Test (AUDIT) questionnaire Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) questionnaire
CAGE test The Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire helps determine lifetime alcohol abuse and dependence in a patient; it does not, however, differentiate past problem drinking from active present drinking. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire is used to determine the effects of alcoholism in the patient. The Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire is used to assess alcohol abuse in women, especially those who are pregnant. The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) questionnaire is especially framed to assess alcohol abuse in older patients. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 98
During an assessment, the nurse finds that a hypertensive patient is a moderate alcohol drinker. Which complication is the patient most likely to develop due to the comorbid condition? Hypersomnia Diabetes mellitus Cardiomyopathy Atrial fibrillation
Cardiomyopathy Hypertension increases the workload to the heart by obstructing the blood flow. This condition coupled with a moderate amount of alcohol per day may further increase the cardiac afterload, leading to cardiomyopathy. Cocaine withdrawal causes hypersomnia but does not lead to cardiomyopathy. Consumption of alcohol in moderate amounts by a hypertensive patient may cause glucose levels to rise but does not result in diabetes mellitus. Heavy drinking and binge drinking may result in atrial fibrillation in a hypertensive patient. Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer. p. 93
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.
Chronic drinker Serum aspartate aminotransferase (AST) is an enzyme found in the liver. Chronic alcoholism refers to patients who continue drinking for months even after suffering from alcohol-related disorders. This causes inflammation of the liver, resulting in increased levels of AST. Heavy alcohol drinking refers to patients who drink as many as 4 standard drinks per day. This increases the mean corpuscular volume and increases the risk for various diseases. Moderate drinking refers to patients who drink less than 1 or 2 drinks per day; this has no immediate detrimental effect on the liver. Occasional alcohol drinking refers to patients who are not addicted, but drink to maintain social relationships. This does not have any effect on levels of AST enzyme in the liver. p. 100
A patient experiencing alcohol withdrawal has normal levels of serum protein gamma glutamyl transferase (GGT). During the follow-up visit a month later, however, the GGT levels are increased. What could be the reason for this? Chronic heavy drinking Relapse of alcohol dependency Nonalcoholic liver disease Alcohol abstinence for 15 days Alcohol abstinence for 4-5 weeks
Chronic heavy drinking Nonalcoholic Liver disease The serum protein gamma glutamyl transferase (GGT) is a biomarker for alcohol. It is helpful in detecting relapses of alcohol dependency in patients who stop consuming alcohol. Elevated levels of GGT after a period of normal levels indicate that alcoholism has relapsed in the patient. They also indicate that the patient may have nonalcoholic liver disease, which is unrelated to alcohol consumption. Alcohol abstinence for 15 days normalizes the levels of carbohydrate-deficient transferrin (CDT); it does not increase them. Alcohol abstinence for 4 to 5 weeks normalizes, but does not increase, the levels of GGT. Drinking alcohol occasionally does not increase the levels of GGT, but chronic drinking for months will. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 100
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 Alcohol withdrawal causes tactile disturbances, tremors, and autonomic hyperactivity. The patient with tactile disturbances may feel itching, numbness and bugs crawling on the skin. A score of 7 indicates that the patient has continuous hallucinations. A patient with severe hallucinations should be assigned a score of 5. A score of 4 indicates moderate hallucinations, and 6 indicates extreme severe hallucinations. p. 101
Why are older adults at a higher risk of developing complications related to alcohol abuse when compared to their younger counterparts? Due to less muscle mass Due to impaired kidney function Due to potential drug interactions Due to reduced stomach capacity Due to increased hepatic activity
Due to less muscle mass Due to impaired kidney function Due to potential drug interactions Due to aging, older adults tend to have impaired kidney functioning, which increases the bioavailability of alcohol. Alcohol is generally metabolized in the liver. Because older adults lack sufficient muscle mass, alcohol metabolism is retarded, leading to an increased concentration of alcohol in the blood. In addition to these symptoms, older adults may be on several medications, which may interact adversely with alcohol. The stomach capacity of an older adult is 1,500 mL and is reduced in obese patients after dieting. Older adults have reduced hepatic activity, which increases the risk for alcohol-related complications. p. 96
The nurse is planning to perform subjective assessment of a patient who is undergoing treatment for drug abuse. Which nursing actions would help the patient to give reliable data? Ensuring that the assessment setting is quiet Asking the patient questions in a private setting Asking the patient to bring a friend or loved one to the assessment Assuring the patient that any information provided will be kept confidential Ensuring that the patient is given antidepressants before the assessment
Ensuring that the assessment setting is quiet Asking the patient questions in a private setting Assuring the patient that any information provided will be kept confidential Because it is difficult to obtain a drug addict's heath history, the nurse should follow proper measures to obtain reliable data from the patient. The nurse should ensure that the setting in which the patient is assessed is quiet so that the patient is not distracted. The assessment area should also be private, so the patient is more likely to be open and honest. The patient may be reluctant to reveal personal information to others; therefore, the nurse should assure that the information given will be kept confidential. The patient may be tempted to understate his or her drug use in front of others and may be more forthcoming with information in a private conversation, so the nurse should not tell the patient to bring a friend or loved one. A patient who is taking medication may not be able to provide reliable data. Therefore, the nurse should ensure that the patient is not under the influence of any medication or substance during the assessment. p. 96
Which biochemical parameter is checked in addition to carbohydrate-deficient transferrin (CDT) levels to assess the extent of alcohol abuse in female patients? Mean corpuscular volume (MCV) Blood alcohol concentration (BAC) Gamma glutamyl transferase (GGT) Serum aspartate aminotransferase (AST)
Gamma glutamyl transferase (GGT) It is observed that women have higher levels of carbohydrate-deficient transferrin (CDT) than men do. Thus, the levels of gamma glutamyl transferase (GGT) are checked in addition to levels of carbohydrate-deficient transferrin (CDT) to assess the extent of alcohol abuse in female patients. An increase in mean corpuscular volume (MCV) is observed if the patient has been involved in heavy drinking for 4 to 8 weeks. Blood alcohol concentration (BAC) in the patient can be assessed by performing the breath alcohol analysis test; this test indicates the presence of alcohol in the blood. Increase in serum aspartate aminotransferase (AST) indicates that the patient is a chronic drinker. p. 100
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) Glutamyl transferase (GGT), serum aspartate aminotransferase (AST), carbohydrate deficient transferrin (CDT), and mean corpuscular volume (MCV) are the biomarkers that provide evidence of drinking problems. Elevation of CDT occurs in patients who drink 50 to 80 grams of alcohol per day for at least 1 week. Thus, the nurse may observe increased CDT levels in this patient. MCV increases during heavy alcohol drinking for 4 to 8 weeks. Chronic alcoholic drinking for 4 to 8 weeks elevates GGT levels. Chronic alcohol drinking for more than a month may raise AST levels. p. 100
While conducting an assessment, the nurse finds that a patient has nausea, vomiting, and malaise. The nurse also observes tremors of the tongue and eyelids. Which additional findings would the nurse expect to discover in a patient experiencing sedative withdrawal? Insomnia Loss of appetite Grand mal seizures Desire to smoke Orthostatic hypotension
Insomnia Grand mal seizures Orthostatic hypotension Sedative withdrawal causes acute GABA underactivity as well as glutamate overactivity, which may lead to sensitization and hyperexcitability of the central nervous system. The withdrawal results in insomnia, seizures, and autonomic hyperactivity such as orthostatic hypotension. Cannabis withdrawal may cause loss of appetite and sweating but not seizures. Nicotine withdrawal causes restlessness, depression, and desire to smoke. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 103
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 Opioid withdrawal causes lacrimation, tachycardia, sweating, diarrhea, and irritability. Lacrimation is excessive secretion of tears. Abrupt cessation of opioid consumption causes central nervous system stimulation, which may lead to tachycardia, sweating, diarrhea, and irritability. Opioid withdrawal may cause insomnia; hypersomnia occurs due to amphetamine withdrawal. Pinpoint pupils and decreased blood pressure are the characteristics of opiate abuse, not opiate withdrawal. Dilation of pupils and increased blood pressure occur during opiate withdrawal. p. 103
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 Gamma glutamyl transferase (GGT) is an enzyme that transfers gamma-glutamyl functional groups and is an important biomarker of alcohol drinking. Liver diseases may damage the liver, which further causes an increased GGT level. GGT levels may increase in response to alcohol relapse in patients undergoing therapy. Chronic alcohol drinking damages the liver; therefore, GGT levels increase. GGT levels return to normal levels within 4 to 6 weeks of alcohol abstinence. Occasional alcohol drinking does not damage the liver, because alcohol is consumed infrequently; therefore, GGT levels would not be elevated. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 100
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 Alcohol abuse in a patient 65 years or older decreases liver metabolism and kidney functioning. These symptoms can lead to liver and kidney problems in these patients. Gastritis generally occurs in alcoholics; therefore, gastrointestinal problems may develop. The 70-year-old patient may not still be working, so employment problems would not necessarily be found. A 70-year-old patient would be more susceptible to health issues in general, but would not necessarily get pneumonia as a result of alcohol abuse. p. 96
Which medications does the nurse expect the primary health care provider to prescribe for a patient with attention deficit hyperactivity disorder (ADHD)? Diazepam (Valium) Meperidine (Meperitab) Methylphenidate (Ritalin) Heroin (diacetylmorphine) Dextroamphetamine (Dexedrine)
Methylphenidate (Ritalin) Dextroamphetamine (Dexedrine) Medications that are used to treat attention deficit hyperactivity disorder (ADHD) in children include methylphenidate (Ritalin) and dextroamphetamine (Dexedrine). These drugs are prescribed in the form of pills. Diazepam (Valium), which belongs to the class of benzodiazepine, is a hypnotic drug. Meperidine (Meperitab) and heroin (diacetylmorphine) are opioid drugs used as analgesics to treat severe pain. p. 104
While caring for a patient in a rehabilitation care facility, the nurse observes that the patient has piloerection, runny nose, and sweating. The nurse decreases the room temperature but finds that the signs persist. What reason does the nurse suspect for this condition in the patient? Opiate withdrawal Alcohol withdrawal Amphetamine withdrawal Benzodiazepine withdrawal
Opiate withdrawal Piloerection, runny nose, and sweating are the symptoms observed when an opiate abuser withdraws from drug use. These symptoms occur when the central nervous system tries to regain its normal functions. Withdrawal symptoms of alcohol abuse include coarse tremor of the hands, tongue, and eyelids, and autonomic hyperactivity. Dysphoric mood, fatigue, insomnia, hypersomnia, and psychomotor agitation are signs associated with amphetamine withdrawal. Withdrawal symptoms of benzodiazepines include autonomic hyperactivity, orthostatic hypotension, and coarse tremors of the hands, tongue, and eyelids. p. 103
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 in early remission After entering treatment for alcohol use, this patient has not met any criteria for alcohol use disorder for 6 months. Despite the ongoing cravings for alcohol, this patient can be classified as being in early remission for alcohol use disorder. The patient will not be classified as being in sustained remission until he or she has gone 12 months without meeting any of the criteria for alcohol use disorder. If the patient begins to drink again, or meets two to five of the criteria, then he or she may be reclassified as having mild or moderate severity alcohol use disorder. p. 91
Which assessment finding is significant in a patient undergoing pharmacotherapy for alcohol withdrawal? Pulse rate Blood pressure Respiratory rate Body temperature Red blood cell (RBC) size
Pulse rate Blood pressure Respiratory rate Body temperature The nurse should assess the vital signs of the patient, including pulse rate, blood pressure, and respiratory rate, then score these signs based on the 10 criteria of the Clinical Institute Withdrawal Assessment (CIWA) scale. Deteriorated vital signs indicate that the patient is in advanced withdrawal stages or has medication overdose. Assessment of red blood cell (RBC) size is done in order to determine mean corpuscular volume. Body temperature is determined in patients who continue to abuse alcohol. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 100
The nurse is caring for an adolescent patient who is febrile. The nurse finds that the patient is anxious and has an irregular heartbeat and tremors. What does the nurse identify as the basis for these findings? Alcohol abuse Stimulant abuse Alcohol withdrawal Stimulant withdrawal
Stimulant abuse Stimulant abuse or overdose results in anxiety and tremors. The patient may also experience panic, an irregular heartbeat, and fever. The stimulants increase the effect of neurotransmitters such as norepinephrine and dopamine in the brain. Alcohol abuse causes symptoms like altered perception and euphoria. Alcohol withdrawal results in autonomic hyperactivity, vomiting, and depression. Stimulant withdrawal in adolescents and young adults may lead to fatigue and depression. p. 104
A patient who is admitted for alcohol withdrawal reports a headache. The nurse assesses the patient and gives a score of 3 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). What is the reason the nurse gives this score? The patient has a mild headache. The patient has a very mild headache. The patient has a moderate headache. The patient has a very severe headache.
The patient has a moderate headache. The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is used to assess a patient's alcohol withdrawal symptoms, and various scores are given for each individual withdrawal symptom. The score given for a moderate headache on this scale is 3. Patients who report a mild headache are given a score of 1. If the patient has a very mild headache, the patient is given a score of 2. A score of 6 is given for patients who have very severe headaches. p. 102
While assessing a patient who abuses alcohol and drugs, the nurse finds that the patient has fever, irregular tremors, and tachycardia. What reason does the nurse expect to be behind such a patient's condition? The patient abuses cannabis. The patient abuses cocaine. The patient has alcohol withdrawal symptoms. The patient has nicotine withdrawal symptoms.
The patient has alcohol withdrawal symptoms. Some patients who are alcoholics may have delirium tremens when they abruptly try to stop drinking alcohol. This is a condition characterized by an altered mental state and autonomic hyperactivity leading to a cardiovascular collapse. Cannabis abuse does not cause delirium tremens but causes symptoms such as reddened eyes, dry mouth, and increased appetite. Hallucinations, hypervigilance, and euphoria may occur during cocaine abuse. Nicotine withdrawal causes restlessness, depression, and awakening at night. p. 102
The nurse is caring for a patient who is undergoing alcohol withdrawal therapy. The nurse assesses the patient on the Clinical Institute Withdrawal Assessment (CIWA) and decides to follow the prescribed scheduled drug for treating alcohol withdrawal. What could be the reason for such an intervention? The patient has scored 6 on the CIWA scale. The patient has scored 9 on the CIWA scale. The patient has scored 11 on the CIWA scale. The patient has scored 16 on the CIWA scale.
The patient has scored 16 on the CIWA scale. The Clinical Institute Withdrawal Assessment (CIWA) is the most sensitive scale for objective measurement in patients. It is quantified to measure the progress of withdrawal in patients who are undergoing withdrawal therapy for alcohol abuse. Scores greater than or equal to 15 indicate that the patient is stable and would need the scheduled drug for treating alcohol withdrawal. This intervention may help prevent advanced withdrawal stages and overmedication. If the patient scores 6 on the CIWA scale, the nurse can assess the patient's vital signs every 4 hours for 72 hours and provide PRN medications, which are given when in need. If the patient score is greater than 8 but less than 15 on the CIWA scale, the nurse should take vital signs every hour for 8 hours and provide PRN medications. Test-Taking Tip: Identifying the content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. p. 100
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 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is used to assess a patient's alcohol withdrawal symptoms. If the nurse sees sweat beads on the patient's forehead while observing for paroxysmal sweating, then the score is 4. If the nurse does not observe sweating in the patient, the score is 0. If the nurse sees that the patient is completely drenched in sweat, the score is 7. If the patient has barely perceptible sweating, but the palms are moist; the score is 1. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 101