Ch. 19: Addiction PrepU
A nurse suspects that a client is experiencing alcohol withdrawal based on assessment of which of the following? - Bradycardia - Hypotension - Elevated temperature - Slurred speech
Elevated temperature Explanation: A client experiencing alcohol withdrawal may exhibit tremors; seizures; increased temperature, pulse and blood pressure; and delirium tremors. Slurred speech would be seen as an effect of alcohol.
An appropriate goal for a client newly admitted to the unit for alcohol withdrawal is what? - Verbalize feeling safe and comfortable. - Demonstrate knowledge of the deleterious effects of alcohol. - Attend two Alcoholics Anonymous meetings each week. - Make amends to people in his or her life that he or she has harmed.
Verbalize feeling safe and comfortable. Explanation: The client should verbalize feeling safe and comfortable. The other answer choices are goals for longer-term treatment—i.e., after the detoxification process has been successfully completed.
Which statement most accurately describes the etiology of substance-related disorders? - Substance-related disorders result from the interplay of biologic, genetic, and psychosocial factors. - Substance-related disorders are primarily a result of the presence of an individual's inherently addictive personality. - The primary predictors of substance-related disorders are childhood trauma and parental abuse or neglect. - Substance abuse is a learned behavior.
Substance-related disorders result from the interplay of biologic, genetic, and psychosocial factors. Explanation: Substance-related disorders have a complex etiology, and contributions have been noted from a combination of neurological, genetic, behavioral, and sociocultural sources.
The mental health nurse recognizes that genetic intolerance of alcohol has been documented among which ethnic group? - Asians - Africans - Italians - Germans
Asians Explanation: Asians have a genetic intolerance to alcohol even when consumed in small amounts. Such an intolerance has not been identified in those of African, Italian, or German descent.
Which medication is used to prevent alcohol withdrawal symptoms? - Lorazepam (Ativan) - Clonidine (Catapres) - Folic acid (Folate) - Naltrexone (ReVia)
Lorazepam (Ativan) Explanation: Safe withdrawal usually is accomplished with the administration of benzodiazepines, such as lorazepam, chlordiazepoxide, or diazepam, to suppress the withdrawal symptoms.
A client is admitted to the detoxification unit on Sunday evening. The client discloses that the client's last alcoholic drink was just before the client was admitted to the unit. When can the nurse expect that the client's alcohol withdrawal symptoms will begin? - Monday morning - Tuesday evening - Wednesday morning - Friday evening
Monday morning Explanation: Symptoms of withdrawal usually begin within 12 hours after cessation or marked reduction of alcohol intake.
A client who is abusing substances is to undergo brief intervention. The nurse understands that this technique is most effective for a client who exhibits which symptoms? - Multiple problems involving drug use - High levels of dependence - Short history of drug use - Unstable backgrounds
Short history of drug use Explanation: Brief intervention is most successful when working with individuals who are experiencing few problems with their drug use, have low levels of dependence, have a short history of drug use, and have stable backgrounds.
Which factor would contraindicate the use of disulfiram in the treatment of a client who has an alcohol use disorder? - The client has a demonstrated family history of alcoholism. - The client engages in binge drinking a few times a week rather than drinking consistently each day. - The client uses marijuana in addition to alcohol. - The client had six drinks a few hours ago.
The client had six drinks a few hours ago Explanation: Disulfiram may not be administered to a client who is acutely intoxicated. A family history of alcoholism, marijuana use, and binge drinking do not preclude the use of the drug.
Which are effects of alcohol withdrawal syndrome? Select all that apply. - Hand tremors - Seizures - Increased pulse - Delirium tremens - Decreased blood pressure
- Hand tremors - Seizures - Increased pulse - Delirium tremens Explanation: Effects of alcohol withdrawal syndrome include course hand tremors, seizures, increased pulse and blood pressure, and delirium tremens.
High doses of alcohol produce which effect? - Vomiting - Decreased muscle tension - Increased inhibitions - Calmness
Vomiting Explanation: An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression.
A client is prescribed disulfiram as part of the alcohol treatment program to prevent relapse. The client asks a nurse, "How will this drug help me?" Which response by a nurse would be most appropriate? - "It will help to cure your alcoholism." - "It can help to prevent you from drinking." - "It makes the withdrawal symptoms less troublesome." - "It helps to clear the alcohol out of your body."
"It can help to prevent you from drinking." Explanation: Disulfiram (Antabuse)is not a treatment or cure for alcoholism, but it can be used as adjunct therapy to help deter some individuals from drinking while using other treatment modalities to teach new skills on coping with altering abuse behaviors. Disulfiram plus even small amounts of alcohol produces adverse effects. Disulfiram does not affect withdrawal symptoms and does not eliminate alcohol from the body.
A client can expect symptoms of alcohol withdrawal to begin how many hours after the last drink? - 2 - 8 - 16 - 24
8 Explanation: Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake.
According to the psychodynamic theory regarding addiction, it is most important that the nurse assesses the client with an alcohol use disorder by considering what? - Asking the client to describe the client's childhood relationship with the client's parents - Observing the client for antisocial tendencies - Observing how often the client engages in cultural rituals - Asking the client to describe any incidences of physical childhood traumas
Asking the client to describe the client's childhood relationship with the client's parents Explanation: According to the psychodynamic theory regarding addiction, it is most important that the nurse assesses the alcoholic client by asking the client to describe the client's childhood relationship with the client's parents. Children of people with alcohol use disorders are four times more likely to develop alcoholism compared with the general population.
Which group could benefit most from prevention programs? - Children, prior to first use - Adults who have already engaged in substance abuse - Older adults - Infants
Children, prior to first use Explanation: Children who have not yet used substances may be easily influenced because of their age and the fact that they have not already become addicted. Adults and older adults who have already engaged in substance abuse will not benefit as greatly from prevention programs as will children; it is important for prevention to precede the problem that it aims to address Infants will not benefit from prevention programs as they do not have self-efficacy.
Ecstasy is an example of which type of substance? - Hallucinogen - Opioid - Stimulant - Sedative
Hallucinogen Explanation: Ecstasy is an example of a hallucinogen.
The nurse in an outpatient rehabilitation program is speaking with a group of clients who have recently recovered from alcohol abuse. Which issue should the nurse raise before the clients leave for the day? - Remind them that substance dependency is a disease, not a mental disorder. - Suggest that they try to confront other issues in their lives, such as estranged relationships or financial issues. - Help them to identify appropriate diversional activities. - Ask them to make a list of all the people they harmed during their addictions.
Help them to identify appropriate diversional activities Explanation: Clients in recovery typically have devoted much time to their addiction. Substance use is integral to their existence and occupies most of their leisure time. In some cases, it also takes up work and family time. During treatment, clients may find themselves lonely, bored, idle, or conflicted about what to do with so much "free" time. They need to plan activities to minimize the temptation to revert to alcohol or drug use.
The psychiatric nurse managing the care of a client experiencing alcohol withdrawal instructs unit staff to anticipate that the client may experience which neurological response? - Tactile hallucinations - Gustatory hallucinations - Somatic delusions - Nihilistic delusions
Tactile hallucinations Explanation: Alcohol withdrawal can be the origin of tactile hallucinations. Alcohol withdrawal is not usually the origin of gustatory hallucinations or delusions of any type.
Which statement about clients with a dual diagnosis is accurate? - Addictions and mental disorders should be treated separately. - Chances for recovery for clients with a dual diagnosis are better than average. - Traditional methods of treatment have not been very successful for these clients. - These clients represent a small percentage of hospitalized clients.
Traditional methods of treatment have not been very successful for these clients. Explanation: Traditional methods of treatment for major psychiatric disorders and substance dependency (i.e., substance dependency programs) have not been successful in treating clients with dual diagnoses.
The nurse is interviewing a client with alcohol use disorder. Which client statement would alert the nurse that the client is not coping with their addiction? - "Often I wake up and don't know how I got there or where I am." - "I appreciate the help I'm getting and now I can stop drinking on my own." - "I'm usually happy go lucky but when I drink I get aggressive and angry." - "I have lots of friends that drink a lot more than I do and they have lost their jobs."
"I appreciate the help I'm getting and now I can stop drinking on my own." Explanation: Usually, nurses encounter individuals during crisis when they are seeking professional help. Denial can be expressed in diverse behaviors and attitudes and may not be expressed as an overt denial of the problem. For example, clients may admit to a problem and even thank the nurse for helping them to realize they have a problem but insist they can overcome the problem on their own and do not need outside help. Statements regarding not knowing where they are, how their temperment changes when inhibited by alcohol, and the realization that others have lost their jobs due to alcohol is showing that the client is talking about the effects that alcohol has or could have on themselves.
The nurse is teaching a client admitted with acute alcohol withdrawal about medications used to prevent complications during the withdrawal from alcohol. The nurse recognizes that teaching has been effective when the client makes which statement? - "I will be given a benzodiazepine over several days as a substitution for alcohol." - "A narcotic antagonist will be given to me to block the alcohol in my system." - "Antipsychotic medications will be given to me gradually for my withdrawal." - "By taking a disulfide, I will be able to start my recovery process sooner."
"I will be given a benzodiazepine over several days as a substitution for alcohol." Explanation: Several medications are used to prevent physiologic complications and provide a gradual withdrawal from alcohol. Antianxiety and sedating drugs, such as benzodiazepines, are titrated downward over several days as a substitution for alcohol; the nurse determines that teaching was effective when the client relays the use of benzodiazepines over several days. More teaching would be needed if the client spoke of a narcotic antagonist being used to treat withdrawal or complications because narcotic antagonist use that totally blocked the effects of both alcohol and opioids could cause the client to develop seizures. More teaching would be needed when the client states that antipsychotic drugs will be given for withdrawal, as antipsychotic drugs are used in the treatment of hallucinations (a complication of withdrawal) and not given gradually. More education would be needed if they client made the statement of disulfides being used so that recovery could start sooner, because disulfides are used in alcohol use disorder recovery, not during the acute withdrawal period.
The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement? - "My condition is a degenerative brain disorder caused by nutrient deficiency." - "There is swelling of my brain that is caused by alcohol consumption." - "The inability of my liver to metabolize the alcohol caused this condition." - "Toxins from the alcohol I drank have caused my brain to swell."
"My condition is a degenerative brain disorder caused by nutrient deficiency." Explanation: The nurse determines that teaching is effective when the client states that Wernicke encephalopathy is a degenerative brain disorder caused by deficiency of folic acid and thiamine (and other B vitamins). It is characterized by vision impairment, ataxia, hypotension, confusion, and coma. The statement about swelling of the brain due to alcohol consumption is not a true statement. The statement of metabolism of alcohol in the liver causing this condition is also incorrect and would require further education. The alcohol toxin statement is not accurate.
The nurse is interviewing family members of a client being treated for substance use disorder. Which statement by a family member would alert the nurse to the possibility of codependency? - "We can meet whenever we need to, but it really is inconvenient!" - "My sibling would not drink as much if their spouse was more understanding." - "This has been a difficult situation for all of us and disturbing to the entire family." - "My sibling is so proud and happy to be able to attend the kids' ball games."
"My sibling would not drink as much if their spouse was more understanding." Explanation: The nurse determines that the statement indicating codependence, also described as "enabling," is when an individual in a relationship with a person who abuses alcohol inadvertently reinforces the drinking behavior of the abuser. Excusing the client's substance abuse problem suggests codependency, as with the statement of the sibling's spouse not being understanding. Being flexible but angry, as in the statement of meeting anytime but it not being convenient; and expressing thoughts and feelings openly as in the client's condition being a difficult situation, indicates identification of the problem, not codependency or enabling. Taking pleasure, as in the statement of the sibling being proud and happy, demonstrates positive coping, not enabling behavior.
A client has entered treatment for alcohol dependency at the client's spouse's insistence. The client's spouse has threatened to leave the marriage unless the client seeks treatment. The client admits that the client drinks every day, but that the drinking is well in control. The nurse recognizes the client's comments as denial. What is the best response by the nurse? - "What negative consequences have resulted from your drinking?" - "You're in denial, which is common in the early stages of recovery." - "Your spouse doesn't seem to think your drinking is in control. Do you know why?" - "How much do you drink per day as compared to your friends?"
"What negative consequences have resulted from your drinking?" Explanation: To confront denial, the nurse points to the evidence of severe dysfunction that inevitably appears in the substance abuser's life. Job losses, financial problems, possible estrangement from family and friends, and legal problems are common, and the nurse can respectfully but firmly remind the client that many of these problems are a result of alcohol or drug abuse.
The nurse is providing support to a client's child regarding the parent's alcohol use disorder. When integrating the disease concept treatment approach about this type of disorder, which statement by the nurse would be most effective? - "Your parent's alcohol use problem is a chronic disease but can be treated." - "Your parent wants to stop drinking but the parent is addicted to the alcohol." - "A brief intervention for alcohol use problems is very effective." - "With your parent's cooperation, your parent can go through the detoxification process."
"Your parent's alcohol use problem is a chronic disease but can be treated." Explanation: According to the Disease Concept, alcoholism is considered a chronic disease with modalities in place to help manage it. Thus, the most assuring response by the nurse is, "Your parent's alcohol use disorder is a chronic disease that can be treated." The other statements do not address this concept.
In a person who abuses alcohol or is a chronic drinker, alcohol withdrawal syndrome usually begins within which time frame from abrupt discontinuation or an attempt to decrease consumption? - 12 hours - 18 hours - 24 hours - 48 hours
12 hours Explanation: In clients with alcoholism or in chronic drinkers, alcohol withdrawal syndrome usually begins within 12 hours after abrupt discontinuation or an attempt to decrease consumption.
The client is brought to the emergency room with opioid overdose. After the initial assessment for central nervous system (CNS) function, what will be the nurse's priority action? - Administer naloxone. - Inquire as to what opioid was taken. - Monitor condition with frequent vital signs. - Focus on cognition and ability to arouse.
Administer naloxone Explanation: The priority action would be to administer naloxone, an opioid antagonist. Naloxone is given as a rescue drug when opioid overdose occurs, often seen with extreme drowsiness, slowed breathing, or loss of consciousness occurs. It reverses respiratory depression, sedation, and hypotension caused by the opioid agent. Administration of naloxone is life-saving. Naloxone reverses opioid toxicity. Because the client has opioid overdose, the priority would be to adminster the antagonist. Questioning about what opioid was used may be important but does not take priority over measures to save the client. The initial set of vital signs is important, but without the naloxone the client could die so frequent vitals would not be the priority. Baseline vitals are taken and then monitored more frequently after administration of naloxone. The nurse must treat the problem at hand, which is the focus of the overdose. Cognition and ability to arouse the client should improve after the administration of the opioid antagonist.
The mental health nurse is preparing a presentation about prescription drug abuse to a local community group. When describing the incidence, which age group would the nurse identify as experiencing an increase? - Adolescents - Chronically ill females - Cognitively impaired older adults - Middle-age males
Adolescents Explanation: Alcohol, tobacco, marijuana, and illegal prescription drug use have reached epidemic proportions in the United States, with the incidence rising in younger age groups, particularly among adolescents and young adults.
A client has a history of consuming alcohol almost daily while pregnant. Her newborn baby has growth deficiency and facial malformations. What is the name for the pattern of birth defects that can occur due to exposure to alcohol? - Prenatal alcohol syndrome - Natal alcohol syndrome - Fatal alcohol syndrome - Fetal alcohol syndrome
Fetal alcohol syndrome Explanation: Alcohol is a teratogen, meaning that it crosses the placenta when women drink during pregnancy and can cause adverse fetal effects. The most clearly alcohol-related birth defect is a specific pattern called fetal alcohol syndrome (FAS), the leading known preventable cause of intellectual disability. Manifestations of FAS include prenatal and postnatal growth deficiency; facial malformations, including a small head circumference, flattened midface, sunken nasal bridge, and flattened and elongated groove between nose and upper lip; central nervous system dysfunction; and varying degrees of major organ system malfunction.
A client is admitted to the emergency department after using MDMA (Ecstasy). The nurse identifies this drug as belonging to what class? - Hallucinogen - Hypnotic - Opioid - Sedative
Hallucinogen Explanation: MDMA (3-4 methylenedioxymethamphetamine), or Ecstasy or Molly, is a hallucinogen and is known as a "designer drug" because it is used by teens and young adults as part of the nightclub, bar, and rave scenes. MDMA, similar in structure to methamphetamine, causes serotonin to be released from neurons in greater amounts than normal. Once released, this serotonin can excessively activate serotonin receptors.
Suspicion that a nursing professional is impaired by a substance abuse problem is most supported by which situation? - Having several clients complain that their pain medication is not working - Frequently calling off work for undefined illnesses - Asking to be scheduled for weekend shifts as much as possible - Spending a considerable amount of shift time off the unit
Having several clients complain that their pain medication is not working Explanation: Suspicion that a nursing professional is impaired by a substance abuse problem is most supported by having several clients complain that their pain medication is not working. An additional risk factor for health care providers and chemical dependency is access to and availability of drugs, training in the administration and injection of drugs, and a familiarity with and a frequency of administering drugs. A nurse who is chemically dependent may divert clients' pain medication to self-administer it; the clients then believe that their medication is not working when in fact they did not receive it. The other situations listed may also indicate a substance abuse problem, but there may be other explanations, whereas a pattern of client complaints that pain medication is not working is strong evidence for a substance abuse problem among the staff.
A 47-year-old client has been admitted to the hospital after being found unconscious in a park. Upon regaining consciousness, the client admits to heavy alcohol use over many years. Assessment reveals a low body mass index, low electrolyte levels, and impaired skin integrity. Vital signs are within normal ranges. What nursing diagnosis should be prioritized in the care of this client? - Risk for injury related to chronic alcohol intake - Deficient knowledge regarding the effects of alcohol intake - Imbalanced nutrition: less than body requirements related to chronic alcohol intake - Ineffective coping related to effects of chemical use
Imbalanced nutrition: less than body requirements related to chronic alcohol intake Explanation: High alcohol intake is associated with malnutrition, which can result in low electrolyte levels, low body mass index, and impaired skin integrity. This diagnosis is of more immediate concern than the client's coping, knowledge, or future risk for injury.
Which characteristic of the 12-step program distinguishes it from other programs? - The philosophy that it is possible to reduce the use of substances without abstaining. - It is a self-help group that focuses on total abstinence. - Persons who use this program are independent in their sobriety. - Infrequent attendance is usually successful.
It is a self-help group that focuses on total abstinence. Explanation: Alcoholics Anonymous was founded in the 1930s by alcoholics. This self-help group developed the 12-step program model for recovery, which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. Regular attendance at meetings is emphasized.
An older adult client with liver disease is experiencing alcohol withdrawal. Based on the nurse's understanding of drug therapy, which of the following would the nurse expect to be prescribed? - Chlordiazepoxide - Diazepam - Lorazepam - Fluoxetine
Lorazepam Explanation: Antianxiety and sedating drugs, such as benzodiazepines, are titrated downwardly over several days as a substitution for the alcohol. Chlordiazepoxide (Librium) and diazepam (Valium) have longer half-lives and smoother tapers. Lorazepam (Ativan) is better for the older adult and people with liver impairment. Fluoxetine is not used.
A client with a history of alcohol use disorder has presented to the emergency department with hallucinations and relays being followed by the police. Which action will the nurse take given this information? - Monitor for Korsakoff syndrome from long-term effects of alcohol use. - Prepare for lumbar puncture for viral encephalopathy. - Administer B12 deficiency injection using Z-track method. - Determine if the client is having episodes of cognitive dementia.
Monitor for Korsakoff syndrome from long-term effects of alcohol use Explanation: The nurse must monitor for Korsakoff syndrome, which is a physiologic effect of long-term alcohol use and manifests with hallucinations and making up or confabulating stories to mask the fact that there is significant memory loss. Wernicke encephalopathy is seen in some individuals with history of alcohol abuse. This problem is associated with long-term heavy alcohol use. Chronic alcohol consumption can lead to a variety of nutritional deficiencies such as folic acid and thiamine (not B12), but these deficiencies can be caused by conditions other than alcohol abuse and be present before cognitive impairment. Cognitive dementia can be seen in a number of other conditions but does not relate specifically to alcohol abuse.
A group of nursing students is reviewing information about nutritional supplementation used during alcohol detoxification. The students demonstrate the need for additional review when they identify which of the following as being used? - Naloxone - Thiamine - Folic acid - Magnesium sulfate
Naloxone Explanation: Naloxone (Narcan), an opioid antagonist, is given to reverse the respiratory depression, sedation, and hypertension for opioid intoxication. Multivitamins and adequate nutrition are essential for clients who are withdrawing from alcohol. Because malnutrition is common, other vitamin replacement may be necessary for certain individuals. Thiamine (vitamin B1) is initiated during detoxification, given to decrease ataxia and other symptoms of deficiency. It is usually given orally, 100 mg four times daily, but can be given intramuscularly or by intravenous infusion with glucose. Folic acid deficiency is corrected with administration of 1.0 mg orally four times daily. Magnesium deficiency also is found in those with long-term alcohol dependence. Magnesium sulfate, which enhances the body's response to thiamine and reduces seizures, is given prophylactically for clients with histories of withdrawal seizures.
A nurse is implementing a brief intervention with a client who is abusing alcohol. What action will the nurse perform? - Asking the client questions about alcohol use - Negotiating a conversation with the client about the need to change - Pointing out the inconsistencies in thoughts, feelings, and actions - Helping the client change the way the client thinks about a situation
Negotiating a conversation with the client about the need to change Explanation: Brief intervention involves a negotiated conversation between the nurse and the client that is designed to reduce the substance use. Asking the client questions about substance use refers to screening. Pointing out inconsistencies reflects confrontation. Helping the client change their way of thinking reflects a cognitive approach.
Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan for the client who is in withdrawal must include which nursing interventions? - Vital signs and medications as prescribed - Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered - Suicide precautions because suicide attempts are frequent during withdrawal - Seizure precautions and vital signs
Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered Explanation: Nursing care of the client experiencing withdrawal centers on safety first. The nurse must implement frequent vital sign assessment, seizure precautions, and fall precautions to ensure the client's safety. Withdrawal symptoms must be controlled with medications.
A nurse is assessing a client with bizarre and aggressive behavior in the emergency department. Upon questioning, the client's partner discloses that the client had been smoking PCP. While in the emergency department, the client continues to exhibit signs of PCP-induced psychosis and has required physical restraints. What nursing outcome should the nurse prioritize in the care of this client? - The client will be physically safe and without injury. - The client will demonstrate appropriate social skills. - The client will establish a balance of rest, sleep, and activity. - The client will verbalize acceptance of responsibility for the behavior.
The client will be physically safe and without injury. Explanation: While the client is actively psychotic and restrained, the need for safety is paramount and would be prioritized over establishing healthy routines, taking responsibility, or demonstrating social skills.
A client with opioid addiction is prescribed methadone maintenance therapy. When explaining this treatment to the client, which of the following would the nurse need to keep in mind? - Methadone is a not physiologically addictive. - The drug helps to satisfy the craving for the opioid. - Methadone is a non-opioid drug. - Methadone simulates the high of heroin.
The drug helps to satisfy the craving for the opioid Explanation: Methadone maintenance is the treatment of people with opioid addiction with a daily, stabilized dose of methadone. Methadone is used because of its long half-life of 15 to 30 hours. Methadone is a potent opioid and is physiologically addicting, but it satisfies the opioid craving without producing the subjective high of heroin.
A client is in treatment for depression and alcohol abuse. The client is unwilling to confront substance abuse issues, stating the client uses alcohol to ease feelings of depression. The client's spouse reports that the spouse often has to care for the client when the client is hung over, calling in sick for the client and doing what the spouse can to help the client catch up with household or job responsibilities. The nurse diagnoses the client's family with dysfunctional family processes. The nurse and clients develop a plan of care. Which goal indicates an understanding of the family situation and the linkages between the diagnosis and the outcomes? - The client and spouse will develop better problem-solving techniques. - The client will admit that the client is an alcoholic. - The spouse will refrain from the enabling the client's drinking behaviors. - The spouse will work through anger at the client.
The spouse will refrain from the enabling the client's drinking behaviors. Explanation: Codependency needs attention from staff and counselors to learn to adjust to the sober spouse and to develop a less vigilant, more interdependent relationship. The nurse recommends that family members begin their own recovery by attending support groups such as Al-Anon or Alateen.
A client with chronic alcoholism has been found to have Wernicke encephalopathy. This irreversible complication is characterized by what? - Thiamine, or vitamin B1, deficiency - Hypothalamic and mammillary body lesions - Inability to learn new skills and short-term memory loss - Double vision and rapid eye movement
Thiamine, or vitamin B1, deficiency Explanation: Wernicke encephalopathy is associated with a deficiency in thiamine, or vitamin B1
The nurse is assessing a client who is suspected of having an alcohol use disorder. The nurse asks about daily alcohol intake. The client replies, "The important point is that if I have 10 drinks, I don't get drunk." The nurse determines the client's response as what? - This is an indication of long-term use of alcohol for this client - Suggests the client may pass out and have episodes of memory lapse - The client is minimizing the consumption of alcohol and is in denial - Determines the client may drink frequently but does not have a problem
This is an indication of long-term use of alcohol for this client Explanation: The nurse determines this statement made by the client is indicative of long-term use. Behavioral tolerance to alcohol is manifested by the ability to mask the behavioral effects. For example, the acquired ability not to slur words, to walk straight, and to function in ways that would not be possible in a nondependent person who drinks. The drinking history of alcoholics often reveals the ability to increase tolerance and to maintain this increase for a long time, perhaps several years. The statement does not indicate passing out or memory lapses. The statement does not indicate the client is in denial or that the client does not have a problem.
A nurse is conducting a class for a group of high school students about marijuana use and abuse. The nurse determines that the class needs further discussion when they state which of the following? - Users of marijuana always experience relaxation and euphoria. - Marijuana interferes with coordination and balance. - Marijuana has cardiovascular effects. - Some active ingredients in marijuana have been approved for medical uses.
Users of marijuana always experience relaxation and euphoria Explanation: While pleasurable for most people on most occasions, marijuana use can induce feelings of anxiety and dysphoria. Other potential negative effects include delirium or a psychotic disorder. Ingestion of marijuana disrupts coordination of movement, balance, and reaction time. It can also result in hypotension and tachycardia. Some cannabinoids have been approved for some medical uses, such as treatment of nausea and vomiting resulting from chemotherapy, and research into additional medical uses is ongoing.
A client is admitted to the emergency department for intoxication with alcohol. The client has an unsteady gait, myopathy, and neuropathy and cannot remember past or recent events. When treated with thiamine, the client's symptoms greatly improve. Which condition was the client likely experiencing? - Scurvy - Wernicke-Korsakoff syndrome - Alcohol dependence with memory impairment - Alcoholic dementia
Wernicke-Korsakoff syndrome Explanation: Wernicke-Korsakoff syndrome is the coexistence of Wernicke's encephalopathy and Korsakoff's psychosis. Wernicke's encephalopathy is characterized by ataxia, nystagmus, ophthalmoplegia, and mental status changes. Korsakoff's psychosis involves gait disturbances, short-term memory loss, disorientation, delirium, confabulation, and neuropathy.
A client is experiencing alcohol withdrawal symptoms. Which will the nurse expect to be prescribed to assist with the withdrawal symptoms, acting as a substitute for the alcohol? - benzodiazepines - beta-blockers - anticonvulsants - phenothiazines
benzodiazepines Explanation: Several medications are used to prevent physiologic complications and provide a gradual withdrawal from alcohol. Antianxiety and sedating drugs, such as benzodiazepines, the drugs of choice, are titrated downwardly over several days as a substitution for the alcohol. Antidepressants are usually initiated to treat mood states, and sleep medication is used to promote a regular sleep pattern. Antipsychotic medications are also used if needed. Beta blockers, phenothiazines, and anticonvulsant medication are not routinely used in the gradual withdrawal from alcohol.
The nurse is caring for an adult client that has been admitted to the detoxification unit. Due to acute withdrawal, what cues will the nurse likely assess? - flushed face, headache, and tremors - psychomotor hypoactivity and hypotension - bradycardia and generalized seizures - anhidrosis, hypotonicity, and delusions
flushed face, headache, and tremors Explanation: Because of acute alcohol withdrawal the nurse will likely assess for tremors, headache, flushed face, and hallucinations. The client will also experience hypertension (not hypotension), tachycardia (not bradycardia), and diaphoresis (not anhidrosis). The nurse would assess for hypotension and bradycardia along with decreasing respiratory rate in those with opioid overdose, not withdrawal. Diaphoresis can also be seen in clients experiencing acute myocardial infarction, but because this client is admitted to the detox unit, this is not likely. Anhidrosis, however, increases the risk of clients with heat exhaustion because they cannot sweat to cool the body down.
A client with a long history of alcohol abuse is hospitalized. The client's last drink was at noon. The nurse would anticipate symptoms of withdrawal beginning no later than what time? - 4:00 p.m. - 8:00 p.m. - midnight - 4:00 a.m.
midnight Explanation: In patients with alcoholism and in chronic drinkers, the alcohol withdrawal syndrome usually begins 4 to 12 hours after abrupt discontinuation or attempt to decrease consumption. Since the last drink was at noon, withdrawal symptoms could appear as early as 4:00 p.m. but would almost certainly begin no later than midnight.
A nurse observes a fellow nurse colleague who has an unsteady gait and slurred speech. The nurse suspects that the colleague is impaired. Which would be the appropriate action to take? - privately confront the nurse by asking what is going on with them - talk to other staff members to see if they have noticed anything - report the nurse colleague's behavior to the supervisor on the floor - ignore the nurse colleague's behavior until others notice as well
report the nurse colleague's behavior to the supervisor on the floor Explanation: Nurses need to report suspicions about colleagues to supervisors immediately to ensure client safety. Increasingly, state boards of nursing require nurses to report colleagues whom they suspect have substance use disorders. The first report should be to the impaired nurse's immediate supervisor, with as many documented facts as possible. Nurses should not confront the impaired nurse or talk about their suspicions with the impaired nurse, nor any staff members. Nurses are mandated reporters and this behavior cannot be ignored.
A client with a history of alcohol use disorder is participating in a 12-step Alcoholics Anonymous (AA) program. A nurse determines that the client is at step 2 based on what statement by the client? - "I've admitted to myself and others the wrongdoings I've done." - "I realize that there is a higher power that can help me." - "I know now that I am powerless over alcohol." - "I am making amends to all those who I've harmed."
"I realize that there is a higher power that can help me." Explanation: Coming to believe that a power greater than oneself could help restore sanity reflects the second step of AA. Admitting to one's self and others about wrongdoings reflects step 5 of AA. Admitting powerlessness over alcohol is step 1. Making amends is part of step 9.
While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms? - PERSONS - CAGE - CIWA-Ar - MSE
CIWA-Ar Explanation: Once alcohol withdrawal is suspected, a screening tool such as the CIWA-Ar can assist nurses to identify the severity of symptoms.
Safe alcohol withdrawal usually is accomplished with the administration of which medication classification? - Benzodiazepines - Antipsychotics - Antidepressants - Anticonvulsants
Benzodiazepines Explanation: Benzodiazepines are used for safe withdrawal of alcohol.
The recommended first-line pharmacologic agents for managing severe alcohol withdrawal symptoms are in which class of medications? - Benzodiazepines - Serotonin reuptake inhibitors - Atypical antipsychotics - Major tranquilizers
Benzodiazepines Explanation: The benzodiazepines reduce withdrawal severity, reduce the incidence of delirium, reduce seizures, and have better overall documented efficacy.
The mental health nurse should focus on preventative efforts including educational interventions related to the abuse of prescription drugs on which client group? - Both genders between the age of 12 and 17 - Chronically ill females regardless of age - Cognitively impaired, 60 years of age and older - Males between the age of 25 and 50
Both genders between the age of 12 and 17 Explanation: Prescription drug abuse among youth 12 to 17 years of age has been increasing at an alarming rate, so the mental health nurse concentrates assessments and educational interventions related to the abuse of prescription drugs on both genders between the age of 12 and 17.
A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring? - Alcohol tolerance - Korsakoff's psychosis - Delirium tremens - Wernicke's encephalopathy
Delirium tremens Explanation: Delirium tremens may occur 24 to 72 hours after the client's last drink. Elevation of vital signs accompanies restlessness, tremulousness, agitation, and hyperalertness. Tolerance is a need for markedly increased amounts of alcohol to achieve the desired effect. Korsakoff's psychosis is a form of amnesia characterized by a loss of short-term memory and the inability to learn new skills. Wernicke's encephalopathy is an inflammatory hemorrhagic, degenerative condition of the brain caused by a thiamine deficiency.
Which statements identify positive aspects of methadone as a substitute for heroin? Select all that apply. - It is available in IV form. - It is a legal medication. - It is controlled by a health care provider. - It is available in tablet form.
- It is a legal medication. - It is controlled by a health care provider. - It is available in tablet form. Explanation: Methadone is safer than heroin because it is legal, controlled by a health care provider, and available in tablet form. It is not available in IV form.
A client is experiencing severe alcohol withdrawal. Which would the nurse identify during the assessment that correlates with the withdrawal symptoms? Select all that apply. - Heart rate around 72 beats/min - Marked diaphoresis - Auditory hallucinations - Gross uncontrollable tremors - Increased appetite
- Marked diaphoresis - Auditory hallucinations - Gross uncontrollable tremors Explanation: A person experiencing severe alcohol withdrawal would exhibit marked diaphoresis, auditory and visual hallucinations, a heart rate between 120 and 140 beats/min, gross uncontrollable tremors, and a complete inability to eat or drink.
The nurse is caring for a client with chronic alcohol use disorder that is experiencing an alteration in memory function. Which laboratory result will the nurse correlate with this assessment finding? - decreased thiamine level - increased BUN and creatinine - decreased iron level - increased TSH
decreased thiamine level Explanation: Korsakoff psychosis and Wernicke's encephalopathy both result in memory dysfunction as an outcome of a thiamine deficiency. The other laboratory results do not correlate with the Korsakoff psychosis and Wernicke's encephalopathy.
The nurse is caring for a client who began drinking a six-pack of beer every day in freshman year of college. By sophomore year, the client was drinking two six-packs to get the same effect. After educating the client on the chronic use of alcohol, the nurse determines education has been effective when the client makes which statement describing this phenomena? - "This is typical for college students who abuse alcohol." - "I always anticipate the euphoric feeling of being intoxicated." - "This increase in volume indicates my dependence on alcohol." - "I developed a tolerance to alcohol over this period of time."
"I developed a tolerance to alcohol over this period of time." Explanation: The nurse determines education has been effective when the client identifies the buildup of tolerance. Physical tolerance means that changes occur in the cells of the nervous system so that more of the drug is needed to achieve the desired effect. Stating that this is typical for college students is judgmental and is stereotyping. Dependence on a substance can occur with no increase in volume as indicated in this question. Dependence indicates that the body is dependent on the substance for physical need. Euphoria can come with being intoxicated, and intoxication can occur without a long-term increase in volume. Many who use alcohol can be intoxicated but show no outward signs.
Which client is exhibiting the effects of alcohol tolerance? - A 66-year-old who has been admitted to the emergency department with apparent delirium tremens - A 22-year-old who now drinks nine or ten drinks in order to get the same effect that the client used to get from drinking a six pack - A 59-year-old whose recent CT scan reveals the presence of Wernicke's encephalopathy - A 28-year-old who is experiencing the signs and symptoms of alcohol withdrawal
A 22-year-old who now drinks nine or ten drinks in order to get the same effect that the client used to get from drinking a six pack Explanation: Tolerance is a symptom of alcohol dependence, which is an alcohol use disorder. Alcohol withdrawal and organic brain damage are problems that result directly from the effects of alcohol on the central nervous system and are considered alcohol-induced disorders.
The nurse is caring for a client experiencing alcohol withdrawal. Which intervention will the nurse perform to alleviate the physical effects associated with alcohol withdrawal? - Administer fixed-dose chlordiazepoxide as prescribed. - Give warm baths every 4 hours around the clock. - Have a family member stay with the client during the withdrawal process. - Keep the client occupied with activities.
Administer fixed-dose chlordiazepoxide as prescribed Explanation: Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam, chlordiazepoxide, or diazepam, to suppress the withdrawal symptoms. Withdrawal can be accomplished by fixed-schedule dosing, known as tapering, or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration. Baths may be dangerous for the clients since their sensorium may be altered and they can slip and fall. Often, family members are not allowed to be present during the withdrawal process in rehabilitation units. The client will not be able to focus on any activities while going through withdrawal.
A client admitted for acute alcohol intoxication begins to experience mild sweating, tachycardia, fever, and nausea and vomiting. Of the following, the drug treatment of choice would be what? - Chlordiazepoxide - Haloperidol - Carbamazepine - Paroxetine
Chlordiazepoxide Explanation: Chlordiazepoxide would be the drug of choice to manage alcohol withdrawal.
When discussing methadone treatment with a client, the nurse should include what? - It decreases the severity of heroin withdrawal symptoms. - The cure rate is extremely high. - It takes 1 to 2 years to cure an opiate addict. - It is a nonaddictive treatment.
It decreases the severity of heroin withdrawal symptoms Explanation: Methadone is a substitute for heroin, reducing the severity of heroin withdrawal symptoms. It does not cure heroin addiction, and it is an addictive drug.
Which term describes a situation that occurs when very small amounts of alcohol intoxicates the person after continued heavy drinking? - Tolerance break - Blackout - Tolerance - Intoxication
Tolerance break Explanation: After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol intoxicate the person. A blackout is an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time or any later memory of the behavior. Tolerance occurs when the person needs more alcohol to produce the same effect. Intoxication is use of a substance that results in maladaptive behavior.
A client is receiving methadone maintenance therapy. After teaching the client about this treatment, a nurse determines that the education was successful when the client makes which statement? - "I can have a glass of wine with dinner if I choose." - "I should eat small frequent meals if I get nauseated." - "I should take the drug on an empty stomach." - "I might experience diarrhea with this drug."
"I should eat small frequent meals if I get nauseated." Explanation: A client receiving methadone maintenance therapy may experience nausea. Therefore, the client should eat small, frequent meals to treat the nausea and loss of appetite and should take the drug with food and lie quietly to minimize the nausea. Alcohol should be avoided. Constipation may occur, necessitating the use of a mild laxative.
The nurse is educating a client regarding the use of disulfiram as treatment for alcohol use disorder. Which statement made by the client indicates that teaching is effective? - "I will avoid all products containing alcohol." - "I will avoid operating heavy machinery or driving." - "I will have weekly blood alcohol levels drawn." - "I will limit alcohol consumption to a moderate level."
"I will avoid all products containing alcohol." Explanation: The client must read product labels carefully because any product containing alcohol can produce symptoms, such as sweating, nausea and vomiting, and severe hypotension. The medication does not affect motor response. The client will not need weekly blood alcohol levels drawn.
Which statements identify positive aspects of methadone as a substitute for heroin? Select all that apply. - It is not an opiate. - It is a legal medication. - It is controlled by a health care provider. - It is available in tablet form.
- It is a legal medication. - It is controlled by a health care provider. - It is available in tablet form. Explanation: Methadone is safer than heroin because it is legal, controlled by a health care provider, and available in tablet form. It also does not produce the high of heroin, and withdrawal has fewer symptoms. Methadone is a synthetic opiate; this allows it to be substituted for heroin.
The nurse is performing a history and physical examination on a client with chronic alcoholism. The client has a history of gastritis, esophagitis, elevated liver enzymes, cardiomyopathy, and pancreatitis. Which of these conditions are attributable to the client's history of alcohol abuse? - Pancreatitis and elevated liver enzymes - Gastritis and elevated liver enzymes - Pancreatitis, esophagitis, gastritis, and elevated liver enzymes - All the conditions are attributable to the alcohol abuse
All the conditions are attributable to the alcohol abuse Explanation: Various medical conditions may alert the nurse to the early recognition of alcohol abuse problems, including gastritis or gastric ulcers, pancreatitis, esophagitis, mild to moderate hypertension, cardiomyopathy, arrhythmias, alcoholic hepatitis, cirrhosis of the liver, decreased white blood cell production, decreased granulocyte adherence, and thrombocytopenia, or cancers of the mouth, pharynx, larynx, esophagus, pancreas, stomach, and colon.
