230 Quiz 7
The patient has a loss of balance. (Ataxia means loss of balance. Ataxia does not mean that the patient has hypotension, a blood clot, or an inability to see colors.)
If a patient has a traumatic brain injury (TBI) with ataxia, what does that mean? The patient has hypotension. The patient has a blood clot. The patient cannot see colors. The patient has a loss of balance.
Force was applied to another body part, but the brain was still affected. (TBIs can be direct or indirect. An indirect TBI means that force was applied to another part of the body, but the rebound effect went to the brain. An indirect injury does not imply the TBI was accidental, applied directly to the head, or caused by an object or tool.)
What does it mean if the patient has an indirect traumatic brain injury (TBI)? Force was applied directly to the patient's head. Force was applied to the head by an object or tool, not another body part. Force was applied to another body part, but the brain was still affected. Force was applied to the brain due to an accident and not an intentional injury.
self-help group for which the goal is sobriety." (Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.)
A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: form of group therapy led by a psychiatrist." self-help group for which the goal is sobriety." group that learns about drinking from a group leader." network that advocates strong punishment for drunk drivers."
Client will be medically stabilized while in the hospital. (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.)
A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? Client will return to a predrug level of functioning within 1 week. Client will be medically stabilized while in the hospital. Client will state within 3 days that they will totally abstain from drugs and alcohol. Client will take a leave of absence from college to alleviate stress.
Tolerance (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.)
A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? Intoxication Tolerance Withdrawal Addiction
c. Stimulants (The adverse effects listed may occur with use of stimulants and are commonly an extension of their therapeutic effects. Opioids, alcohol, and depressants do not have these effects.)
A 29-year-old male patient is admitted to the intensive care unit with the following symptoms: restlessness, hyperactive reflexes, talkativeness, confusion and periods of panic and euphoria, tachycardia, and fever. The nurse suspects that he may be experiencing the effects of taking which substance? a. Opioids b. Alcohol c. Stimulants d. Depressants
b. "These cravings may persist for several months." (Cigarette cravings may persist for months after nicotine withdrawal. The other statements are false.)
A 38-year-old male patient stopped smoking 6 months ago. He tells the nurse that he still feels strong cigarette cravings and wonders if he is ever going to feel "normal" again. Which statement by the nurse is correct? a. "It's possible that these cravings will never stop." b. "These cravings may persist for several months." c. "The cravings tell us that you are still using nicotine." d. "The cravings show that you are about to experience nicotine withdrawal."
"It helps prevent relapse by reducing drug cravings." (Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. None of the other options do not accurately describe the action of naltrexone.)
A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? "It helps your mood so that you don't feel the need to do drugs." "It will keep you from experiencing flashbacks." "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." "It helps prevent relapse by reducing drug cravings."
c. Notify the Rapid Response Team. (This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.)
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.
a. Ask the client how long ago the clip was placed. (Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives.)
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.
a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. (All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.)
A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.
c. Risk for acquiring an infection (The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.)
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown
a. Call the provider or Rapid Response Team. (These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.)
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.
b. Perform hand hygiene before client care. (All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.)
A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.
Maintaining neutral head position (To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner's sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.)
A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Grey Turner's sign Maintaining neutral head position Placing the client in the Trendelenburg position Suctioning the client frequently
b. Ensure that informed consent is on the chart. (For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.)
A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.
a. Explain that personality changes are common following brain injuries. (Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings.)
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.
Positioning the client to prevent aspiration (Positioning the client while maintaining cervical spine immobilization to prevent aspiration is the nurse's priority intervention. Maintaining a patent airway is essential especially since this client is vomiting.Calling the Stroke Team would not be necessary. Establishing an IV is important for this client but it is not the first priority. If this client was having a stroke, thrombolytics would be contraindicated because of the fall with head strike.)
A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? Calling the Stroke Team Establishing an IV Positioning the client to prevent aspiration Preparing for thrombolytic administration
a. "I know I can take care of all these needs by myself." (This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.)
A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."
a. Assess whether or not the client can write. (Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia.)
A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.
Changes in breathing pattern (The nurse monitors for changes in breathing pattern. This may be indicative of increased intracranial pressure secondary to compression of areas of the brain responsible for respiratory control. Dizziness is a symptom of brain injury, not increased intracranial pressure. Increasing level of consciousness and reactive pupils are desired outcomes for this client.)
A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils
b. Poor prognosis and cognitive function (The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.)
A client's mean arterial pressure is 60 mmHg and intracranial pressure is 20 mmHg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information
One-on-one supervision (One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.)
A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? Check the patient every 15 minutes Keep the room dimly lit One-on-one supervision Force fluids
"Social drinkers have one or two drinks, once or twice a week." "You describe drinking steadily throughout the day and evening." (The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.)
A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply. "I see," and use interested silence. "I think you are drinking more than you report." "Social drinkers have one or two drinks, once or twice a week." "You describe drinking steadily throughout the day and evening." "Your comments show denial of the seriousness of your problem."
Respiratory (Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority.)
A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? Cardiovascular Neurologic Respiratory Hepatic
a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 (A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.)
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache
b. Client in a coma for 2 weeks from a motor vehicle crash (In order to determine brain death, clients must meet four criteria: 1: coma from a known cause 2: normal or near-normal core temperature 3: normal systolic blood pressure 4: at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.)
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mmHg since admission
b. Is allergic to acetaminophen (Tylenol) d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home (Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.)
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home
Psychosocial (Discussing family members' feelings and coping strategies is a part of a psychosocial assessment. Examining the patient's appearance and reflexes are examples of parts of the physical assessment. Blood tests encompass the laboratory assessment. Imaging techniques like computed tomography and magnetic resistance imaging scans comprise the imaging assessment.)
A nurse is listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury. How does the nurse document this type of assessment? Imaging Physical Laboratory Psychosocial
a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence (After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.)
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
Self-assess personal attitude, values, and beliefs about this health problem. (The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.)
A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? Perform a thorough assessment of the patient. Verify that security services are immediately available. Self-assess personal attitude, values, and beliefs about this health problem. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.
Consult the health care provider. (Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.)
A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? Force fluids. Consult the health care provider. Obtain a clean-catch urine sample. Place the patient in a vest-type restraint.
Substance Abuse and Mental Health Services Administration (SAMHSA) (The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.)
A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? Substance Abuse and Mental Health Services Administration (SAMHSA) Institute of Medicine - National Research Council (IOM) National Council of State Boards of Nursing (NCSBN) American Society of Addictions Medicine
a. A client with a moderate trauma may need hospitalization. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings. ("Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.)
A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.
has symptoms of alcohol-withdrawal delirium. (Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.)
A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: is attempting to obtain attention by manipulating staff. may have sustained a head injury before admission. has symptoms of alcohol-withdrawal delirium. is having an acute psychosis.
Denial (Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one's own personality.)
A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? Denial Introjection Projection Rationalization
Risk for injury (The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care.)
A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? Disturbed sensory perception Ineffective denial Ineffective coping Risk for injury
"An individual is supported by peers while striving for abstinence one day at a time." (Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.)
A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. "The goal of AA is for members to learn controlled drinking with the support of a higher power." "An individual is supported by peers while striving for abstinence one day at a time." "You must make a commitment to permanently abstain from alcohol and other drugs." "You will be assigned a sponsor who will plan your treatment program."
"Tell me what happened the last time you drank." (The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.)
A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? "Sooner or later, alcohol will kill you. Then what will happen to your children?" "I hear a lot of defensiveness in your voice. Do you really believe this?" "If you were coping so well, why were you hospitalized again?" "Tell me what happened the last time you drank."
b. Severe vomiting d. Pulsating headache e. Difficulty breathing f. Sweating (Acetaldehyde syndrome results when alcohol is taken while on disulfiram (Antabuse) therapy. Adverse effects include CNS effects (pulsating headache, sweating, marked uneasiness, weakness, vertigo, others); GI effects (nausea, copious vomiting, thirst); and difficulty breathing. Cardiovascular effects also occur.)
A patient has been taking disulfiram (Antabuse) as part of his rehabilitation therapy. However, this evening, he attended a party and drank half a beer. As a result, he became ill and his friends took him to the emergency department. The nurse will look for which adverse effects associated with acetaldehyde syndrome? (Select all that apply.) a. Euphoria b. Severe vomiting c. Diarrhea d. Pulsating headache e. Difficulty breathing f. Sweating
d. If opioid drugs are used while taking naltrexone, euphoria is not produced; thus, the opioid's desired effects are lost. (Naltrexone works to eliminate the euphoria that occurs with opioid drug use; therefore, the reinforcing effect of the drug is lost.)
A patient has been taking naltrexone (ReVia) as part of the treatment for addiction to heroin. The nurse expects that the naltrexone will have which therapeutic effect for this patient? a. Naltrexone prevents the cravings for opioid drugs. b. Naltrexone works as a safer substitute for the heroin until the patient completes withdrawal. c. The patient will experience flushing, sweating, and severe nausea if he takes heroin while on naltrexone. d. If opioid drugs are used while taking naltrexone, euphoria is not produced; thus, the opioid's desired effects are lost.
substance addiction. (Nicotine meets the criteria for a "substance," the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.)
A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes: cross-tolerance. substance addiction. substance abuse. substance intoxication.
b. Methadone (Opioid withdrawal can be managed with either methadone or clonidine (Catapres). Diazepam and disulfiram are used for treatment of alcoholism, and bupropion is used to assist with smoking cessation.)
A patient in a rehabilitation center is beginning to experience opioid withdrawal symptoms. The nurse expects to administer which drug as part of the treatment? a. Diazepam (Valium) b. Methadone c. Disulfiram (Antabuse) d. Bupropion (Zyban)
b. Osmotic diuretics (Mannitol, an osmotic diuretic, is commonly used to reduce intracranial pressure and cerebral edema resulting from head trauma.)
A patient in the neurologic intensive care unit is being treated for cerebral edema. Which class of diuretic is used to reduce intracranial pressure? a. Loop diuretics b. Osmotic diuretics c. Thiazide diuretics d. Vasodilators
b. He needs to know about the common over-the-counter substances that contain alcohol. (The use of disulfiram (Antabuse) with alcohol-containing over-the-counter products will elicit severe adverse reactions. As little as 7 mL of alcohol may cause symptoms in a sensitive person. Cigarette smoking does not cause problems when taking disulfiram. Disulfiram does not have the same effects as alcohol.)
A patient is being treated for ethanol alcohol abuse in a rehabilitation center. The nurse will include which information when teaching him about disulfiram (Antabuse) therapy? a. He should not smoke cigarettes while on this drug. b. He needs to know about the common over-the-counter substances that contain alcohol. c. This drug will cause the same effects as the alcohol did, without the euphoric effects. d. Mouthwashes and cough medicines that contain alcohol are safe because they are used in small amounts.
Amphetamines (The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.)
A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? PCP Barbiturates Heroin Amphetamines
Opioid withdrawal (Signs and symptoms associated with opioid withdrawal include drug seeking, mydriasis, piloerection (goose bumps), diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea, insomnia, and elevated blood pressure and pulse rate. Nurses must be alert for this behavior in patients seeking medication for subjective pain complaints, especially when accompanied by withdrawal symptoms.)
A patient reports severe back pain and asks the nurse for medication "to take the pain away." Nursing assessment findings on the physical examination include mydriasis (dilated pupils), rhinorrhea (runny nose), diaphoresis, lacrimation (crying), blood pressure of 160/84 mmHg, heart rate of 116 beats/min, and respiratory rate of 24 breaths/min. Which condition would the nurse suspect? Amphetamine overdose Barbiturate overdose Opioid withdrawal Ethanol intoxication
avoid alcohol-based skin products. read labels of all liquid medications. avoid breathing fumes of paints, stains, and stripping compounds. (The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.)
A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) avoid aged cheeses. avoid alcohol-based skin products. read labels of all liquid medications. wear sunscreen and avoid bright sunlight. maintain an adequate dietary intake of sodium. avoid breathing fumes of paints, stains, and stripping compounds.
Use of intraventricular catheter (When an intraventricular catheter is used, a hole is created in the skull by drilling, and the catheters are inserted through the brain to an area where the cerebrospinal fluid is present. It is the most invasive device, and cerebrospinal fluid leakage may occur near the insertion site. Use of subarachnoid bolt or screw, subdural/epidural catheter or sensor, and fiberoptic transducer-tipped catheter may not cause cerebrospinal fluid leakage. This is because the catheters are not placed in the region of the cerebrospinal fluid.)
A patient with a traumatic brain injury underwent monitoring of the intracranial pressure. Suddenly, it resulted in leakage of the cerebrospinal fluid. What would be the possible reason for the leakage? Use of intraventricular catheter Use of subarachnoid bolt or screw Use of subdural/epidural catheter or sensor Use of fiberoptic transducer-tipped catheter
Residential program (Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.)
A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? 1-week detoxification program 12-step self-help program Long-term outpatient therapy Residential program
b. Assess the client's sodium level. (This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.)
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.
hallucinogen ingestion. (The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.)
An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a schizophrenic episode. opium intoxication. hallucinogen ingestion. cocaine overdose.
Acceleration injury (An acceleration injury is one in which an external force contacts the head and places the head in sudden motion. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. A focal injury is confined to a specific area of the brain. A diffuse injury is when many areas of the brain are damaged.)
An injury that is caused by an external force contacting the head, placing the head in sudden motion, is known as what? Focal injury Diffuse injury Deceleration injury Acceleration injury
Propofol (Propofol is an IV sedative-hypnotic drug used for induction and maintenance of anesthesia as well as for sedation in patients who are intubated and mechanically ventilated in the ICU. It has a rapid onset and short duration of action, allowing for easy titration and maintenance of the patient's level of consciousness.)
An intubated, mechanically ventilated patient in the intensive care unit (ICU) is becoming increasingly restless and anxious. The nurse expects to administer which intravenous (IV) anesthetic drug? Propofol Fentanyl Morphine sulfate Naloxone
Ch. 22: Substance-Related and Additive Disorders
Ch. 22: Substance-Related and Additive Disorders
Ch. 45: Care of Critically Ill Patients with Neurologic Problems
Ch. 45: Care of Critically Ill Patients with Neurologic Problems
codependence. (Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario.)
At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as: codependence. role reversal. assertiveness. homeostasis.
"While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." (During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.)
During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." "It will be important for you to structure life to avoid as much stress as you can and provide social protection." "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." "It is good that you are supportive of your spouse's sobriety and want to help maintain it."
Within 48 hours after impact (Acute SDHs present within 48 hours after impact. A subacute SDH will present within 48 hours to two weeks after impact. A chronic SDH will present from two weeks to several months after impact.)
During which time frame does an acute subdural hematoma (SDH) present? Within 48 hours after impact Within one week after impact Within two weeks after impact Within two months after impact
"Make your loved one responsible for the consequences of behavior." (Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.)
Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. "Alcoholism is a lifelong disease. Relapses are expected." "Use search and destroy tactics to keep the home alcohol free." "It's important that you visit your family member on a regular basis." "Make your loved one responsible for the consequences of behavior."
Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. (The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.)
In the emergency department, a patient's vital signs are: BP 66/40 mmHg pulse 140 beats/min respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.
Empathetic, supportive (Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.)
Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. Empathetic, supportive Cool, distant Skeptical, guarded Confrontational
Monitor vital signs. (Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.)
Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. Monitor vital signs. Observe for depression. Awaken the patient every 15 minutes. Use warmers to maintain body temperature.
state, "I know I need long-term treatment." (The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.)
Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will: state, "I know I need long-term treatment." use denial and rationalization in healthy ways. identify constructive outlets for expression of anger. develop a trusting relationship with one staff member.
nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. (The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.)
Symptoms of withdrawal from opioids for which the nurse should assess include: dilated pupils, tachycardia, elevated blood pressure, and elation. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. mood lability, incoordination, fever, and drowsiness. excessive eating, constipation, and headache.
c. Needs frequent re-orientation (This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.)
The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care
Stimulants (Stimulants of abuse include amphetamines and often are related to anxiety, talkativeness, headaches, weakness, restlessness, and cardiac dysrhythmias.)
The nurse is providing care for a patient in the emergency department who reports a headache and weakness and is noted to have cardiac dysrhythmias on the electrocardiogram. The patient is talkative, restless, anxious, and asking to leave the emergency department. The nurse suspects that the patient might be taking which abuse substance? Stimulants Depressants Alcohol Opioids
rehearsing techniques to handle anticipated stressful situations. assisting the patient to identify life skills needed for effective coping. informing the patient of physical changes to expect as the body adapts to functioning without substances. (Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.)
The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply) rehearsing techniques to handle anticipated stressful situations. advising the patient to accept residential treatment if relapse occurs. assisting the patient to identify life skills needed for effective coping. advising isolating self from significant others until sobriety is established. informing the patient of physical changes to expect as the body adapts to functioning without substances.
Asymmetric pupils (The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache and a head laceration, can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.)
The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? Amnesia Asymmetric pupils Headache Head laceration
Tremors Agitation Hypertension (Common symptoms and signs of alcohol withdrawal include increased blood pressure, pulse, tremors, and agitation. The signs and symptoms may vary depending on the patient's usage pattern, the preferred type of ethanol, and the presence of comorbidities.)
The nurse is caring for a patient with a history of chronic alcohol abuse. The nurse recognizes the need to closely monitor the patient for which withdrawal signs and symptoms? Select all that apply. Tremors Agitation Bradycardia Difficulty breathing Hypertension
d. Client who has a temperature of 102° F (38.9° C) (A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO₂ of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.)
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mmHg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO₂ of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)
Increased alertness Weight loss Elevated mood (The abuse of stimulants is related to their ability to cause elevation of mood, reduction of fatigue, a sense of increased alertness, and invigorating aggressiveness. Other signs and symptoms include diarrhea and abdominal cramps, not constipation.)
The nurse is educating a group of college students about substance abuse. When discussing the potential use and abuse of stimulants, the nurse is aware these drugs are commonly abused and cause what signs and symptoms? Select all that apply. Constipation Increased alertness Weight loss Elevated mood Decreased aggressiveness
Achieving the highest level of functioning (The most important nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible.The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.)
The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? Achieving the highest level of functioning Increasing cerebral perfusion Preventing further injury Preventing skin breakdown
Decorticate positioning (In a postoperative craniotomy client, the nurse must immediately report decorticate positioning to the provider. The major complications of a craniotomy are increased intracranial pressure from cerebral edema or hydrocephalus and hemorrhage. Decorticate positioning indicates damage to the pathway between the brain and the spinal cord. Periorbital edema and a small-to-moderate amount of serosanguineous drainage are expected after a craniotomy. Ecchymoses in the facial region, especially around the eyes, are expected after a craniotomy.)
The nurse is monitoring a client after a craniotomy. Which sign/symptom does the nurse report immediately to the provider? Periorbital (eye socket) edema Bilateral ecchymoses (bruising) of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning
a. Agitation c. Tremors d. Systolic blood pressure higher than 200 mm Hg (Signs and symptoms of severe ethanol withdrawal (delirium tremens) include systolic blood pressure higher than 200 mm Hg, diastolic blood pressure higher than 140 mm Hg, pulse rate higher than 140 beats/min, temperature above 101° F (38.3° C), tremors, insomnia, and agitation.)
The nurse is monitoring a patient who is experiencing severe ethanol withdrawal. Which are signs and symptoms of severe ethanol withdrawal? (Select all that apply.) a. Agitation b. Drowsiness c. Tremors d. Systolic blood pressure higher than 200 mm Hg e. Temperature over 100° F (37.7° C) f. Pulse rate 110 beats/min
Mannitol (Osmitrol) (In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema. Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.)
The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin)
Tolerance (Tolerance is defined as requiring an increased amount of drugs in the system to have the same desired effect)
The nurse is reading a patient's substance abuse history on admission to inpatient rehabilitation. The patient states to the nurse, "I have been increasing my drug dosage to get the same effect." What is the patient experiencing? Habituation Tolerance Physiological dependence Addiction
Pain relief is best obtained by administering analgesics around the clock. (When pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis, but dosages should always be within the dosage guidelines for each drug used. The around-the-clock (or "scheduled") dosing maintains steady-state levels of the medication and prevents drug troughs and escalation of pain.)
The nurse plans pharmacologic management for a patient with pain. The nurse should administer the pain medication based on what dosage schedule? Pain relief is best obtained by administering analgesics around the clock. Administer the analgesic when the pain level reaches a "6" on a scale of 1 to 10. Opioid analgesics should not be used for more than 24 hours to prevent drug addiction. Analgesics should be administered as needed (prn) to minimize adverse effects.
The patient's brain is bruised. (Contused is another word for bruised. If the patient had a shearing injury, the health record would indicate nerve axonal injury. If the patient's brain were torn, the health record would indicate a laceration. A direct injury does not describe a contusion.)
The nurse reads the patient's health record and sees that the patient's brain is contused. What does the nurse infer from this? The patient's brain is torn. The patient's brain is bruised. The patient has a shearing injury. The patient had a direct injury.
Anuria related to end-stage kidney disease (Mannitol does not influence urine production; it only increases existing urine output. It is not metabolized but excreted unchanged in the urine by the kidneys. Thus, if no urine is produced (anuria), mannitol is not excreted, which increases blood volume. Excess blood volume may cause the undesirable adverse effect of pulmonary edema.)
The nurse would question the use of mannitol (Osmitrol) for which patient condition? Increased intraocular pressure Anuria related to end-stage kidney disease Cerebral edema from head trauma Oliguria from acute renal failure
consider each diagnosis primary and provide simultaneous treatment. (Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.)
The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should: provide long-term care for the patient in a residential facility. withdraw the patient from cannabis, then treat the schizophrenia. consider each diagnosis primary and provide simultaneous treatment. first treat the schizophrenia, then establish goals for substance abuse treatment.
Readiness to change and support system (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.)
The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? Readiness to change and support system Current college performance Financial ability Availability of immediate family to come to meetings
Decrease in intracranial pressure (Mannitol is an osmotic diuretic that pulls fluid from extravascular spaces into the bloodstream to be excreted in urine. This decreases intracranial pressure and cerebral blood volume, increases excretion of medications, decreases urine osmolality, and increases serum osmolality.)
To evaluate the therapeutic effects of mannitol (Osmitrol), the nurse should monitor the patient for which clinical finding? Decrease in intracranial pressure Decrease in serum osmolality Increase in urine osmolality Increase in cerebral blood volume
An injury in which the skull is fractured (When the skull is fractured or pierced by a penetrating object, this is known as an open TBI. When only the brain tissue is damaged, this is a closed TBI. When the skull is still intact, this is a closed TBI. Increased ICP can cause closed, not open, TBIs.)
What is the best explanation of an open traumatic brain injury (TBI)? An injury in which the skull is fractured An injury in which the skull remains intact An injury that damages only the brain tissue An injury in which there is increased intracranial pressure (ICP)
Increased intracranial pressure (ICP) (Increased ICP is the leading cause of death in patients who reach the hospital alive after having head trauma. Internal bleeding is a risk factor for death, but is not the leading cause. Hypoxia and hypotension commonly cause secondary injuries but are not the leading cause of death.)
What is the leading cause of death from head trauma in patients who reach the hospital alive? Hypoxia Hypotension Internal bleeding Increased intracranial pressure (ICP)
Level of consciousness (Level of consciousness (LOC) is the most important variable to assess with any brain injury. Heart rate, blood pressure, and body temperature can be assessed after LOC is evaluated.)
What is the most important variable to assess with any brain injury? Heart rate Blood pressure Body temperature Level of consciousness
Tolerance has developed. (Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.)
When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? Tolerance has developed. Antagonistic effects are evident. Metabolism of the alcohol is now delayed. Pharmacokinetics of the alcohol have changed.
Respiratory rate (The most serious adverse effect of opioid analgesics is respiratory depression.)
When assessing for the MOST serious adverse effect to an opioid analgesic, what does the nurse monitor for in this patient? Blood pressure Respiratory rate Mental status Heart rate
Drowsiness, constricted pupils, slurred speech (Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.)
Which assessment findings are likely for an individual who recently injected heroin? Anxiety, restlessness, paranoid delusions Muscle aching, dilated pupils, tachycardia Heightened sexuality, insomnia, euphoria Drowsiness, constricted pupils, slurred speech
An abnormal increase in cerebrospinal fluid (Hydrocephalus is an abnormal increase in cerebrospinal fluid. If left untreated, this condition can lead to increased intracranial pressure. A collection of blood is a blood clot. The shifting and herniating of brain tissue downward describes brain herniation. The fluid accumulation between the cells of the brain describes interstitial edema.)
Which best describes hydrocephalus? A collection of blood An abnormal increase in cerebrospinal fluid The shifting and herniating of brain tissue downward The fluid accumulation between the cells of the brain
Occur after the initial injury (Secondary brain injuries are injuries that occur after the initial injury and worsen the patient's outcome. They do not always result in contusion. Secondary injuries do not cause additional injuries, though they can negatively affect other physiological processes. Secondary brain injuries are not necessarily caused by indirect forces.)
Which describes secondary brain injuries? Result in contusion Caused by indirect forces Occur after the initial injury Cause additional injuries in the body
Simple and safe (Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip.")
Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? Simple and safe Stimulating and colorful Active and bright Confrontational and challenging
Achieve physiologic stability. (The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.)
Which goal for treatment of alcoholism should the nurse address first? Learn about addiction and recovery. Develop a peer support system. Develop alternate coping strategies. Achieve physiologic stability.
Naltrexone (ReVia) (Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.)
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? Bromocriptine (Parlodel) Disulfiram (Antabuse) Methadone (Dolophine) Naltrexone (ReVia)
Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. (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.)
Which statement is true regarding substance addiction and medical comorbidity? Most substance abusers do not have medical comorbidities. There has been little research done regarding substance addiction disorders and medical comorbidity. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
Opioid (Naltrexone (ReVia), an opioid antagonist, is used to treat opioid abuse or dependence. Naltrexone works by blocking the opioid receptors so that use of opioid drugs does not produce euphoria. When euphoria is eliminated, the reinforcing effect of the drug is lost.)
While obtaining a medication history from a patient, the nurse notes that the patient is currently prescribed naltrexone (ReVia). The nurse should question the patient about a previous history of which substance abuse? Amphetamine Barbiturate Alcohol Opioid
