CHAPTER 13 SUBSTANCE-RELATED DISORDERS

36. All states had to conform to the __________ g/dL blood level standard of legal intoxi- cation by 2004 or risk loss of federal highway funding.

✅ 0.08 g/dL A federal bill was passed in October 2000 making a 0.08 g/dL blood level the standard of intoxication for all states. All states had to con- form to this law or risk loss of federal highway construction assistance. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to know the blood alcohol level that indicates intoxication. This is often referred to as the "legal limit."

27. Three days after surgery to correct a perforated bowel,a client begins to display signs and symptoms of tremors, increased blood pressure, and diaphoresis. What should the nurse suspect? 1. Concealed hemorrhage. 2. Withdrawal from alcohol or other central nervous system depressants. 3. Malignant hyperpyrexia. 4. Neuroleptic malignant syndrome.

1. Concealed hemorrhage occurs internally from a blood vessel that is no longer sutured or cauterized. The early symptoms include restlessness (not tremors), anxiety, and thirst. Pulse increases and blood pressure decreases, not increases. ✅2. Tremors, increased blood pressure, and diaphoresis all are signs of central nervous system (CNS) rebound that occurs on withdrawal from any CNS depressant. The 3-day timeframe presented in the question is the typical period in which a withdrawal syndrome might occur. 3. Malignant hyperpyrexia is a severe form of pyrexia that occurs because of the use of muscle relaxants and general inhalation anesthesia. This condition is rare and occurs during or immediately after surgery. In the question, there is no mention of the client's having an elevated temperature. 4. Neuroleptic malignant syndrome is a rare, but potentially fatal, complication of contin- ued treatment with neuroleptic drugs. In the question, there is no mention that the client has received any antipsychotic medications TEST-TAKING HINT: This question requires that the test taker recognize the importance of always reviewing a client's history. CNS depressant dependency should be noted to alert the nurse for the potential problem of withdrawal. This dependency also should be validated with signifi- cant others and family because the defense mechanism of denial may be used by the client, and dependency may be minimized.

6. A client reports drinking one to two drinks when drinking behavior first began. Now the client reports drinking at least six drinks with every episode in order to ìhave a good time. Which term would best describe this phenomenon? A) Dependence B) Intoxication C) Tolerance D) Withdrawal

ANS:C Feedback: As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect. Intoxication is use of a substance that results in maladaptive behavior. Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases. Substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.

19. A client with alcohol dependence is admitted to the hospital with pancreatitis. Which intervention should be included in the client's plan of care? A) Fluid restriction of 1000 mL per 24 hours B) Glucometer checks b.i.d. C) High-protein diet D) Protective isolation precautions

Ans: B Feedback: Pancreatitis can cause elevated serum glucose levels. The other choices are not necessarily appropriate.

20. A client is admitted for a drug overdose with a Barbiturate? Which is the priority nursing action when planning care for this client? A) Check the client's belongings for additional drugs. B) Pad the side rails of the bed because seizures are likely. C) Prepare a dose of ipecac, an emetic. D) Monitor respiratory function.

Ans: D Feedback: CNS depressants depress respiratory functioning. Answer choices A, B, and C would not be priority nursing actions in this situation.

35. The nurse is educating a client about how to avoid sources of stimulation. What produces the least significant stimulation to the central nervous system? 1. Brewed coffee. 2. Excedrin Migraine. 3. Tequila shooter. 4. Filtered cigarettes.

Caffeine is a central nervous system (CNS) stim- ulant. The two most widely used stimulants are caffeine and nicotine. 1. A 5- to 6-ounce cup of brewed coffee contains 90 to 125 mg of caffeine. 2. Excedrin Migraine is a combination of aspirin and acetaminophen and contains 65 mg of caffeine. ✅3. Tequila is distilled liquor. Alcohol is a CNS depressant, not a stimulant. 4. Any cigarettes, including those with filters, contain nicotine, a CNS stimulant. TEST-TAKING HINT: To answer this question correctly, the test taker must be able to identify products containing nicotine and caffeine, and recognize that these products stimulate the CNS. Nicotine is contained in all tobacco products. Caffeine is readily available in every supermarket and grocery store as a common ingredient in over-the-counter medications, coffee, tea, colas, and chocolate.

16. A client with a long history of alcohol abuse is seen in the emergency department. The client complains of extreme muscle pain, swelling and weakness of extremities, and red- dish-tinged urine. What lab value related to this client's symptoms would the nurse expect to assess? 1. An elevated gamma-glutamyl transferase. 2. An elevated enzyme-linked immunosorbent assay. 3. An elevated white blood cell count. 4. An elevated creatine phosphokinase.

Creatine phosphokinase (CPK) is elevated with alcoholic myopathy. The symptoms of alcoholic myopathy include extreme muscle pain, swelling and weakness of extremities, and reddish-tinged urine. 1. An elevated gamma-glutamyl transferase is an indication of chronic alcoholism, but is not indicative of the client's symptoms described in the question. 2. Enzyme-linked immunosorbent assay tests for the presence of antibodies to HIV, the virus that causes AIDS. This serological test is not performed to substantiate the diagnosis of alcoholic myopathy. 3. An elevation in white blood cell count would indicate the presence of an infectious process. Testing for alcoholic myopathy would not include a white blood cell count. ✅4. An elevated CPK is an indication of alcoholic myopathy. The client symptoms described indicate this complication of alcoholism. TEST-TAKING HINT: To answer this question cor- rectly the test taker must recognize that an ele- vation of CPK may be indicative of alcoholic myopathy.

60. A fasting blood glucose level value is to a sliding scale insulin dosage as a Clinical Institute Withdrawal Assessment (CIWA) score is to: 1. An olanzapine (Zyprexa) dosage. 2. A lithium carbonate (Lithium) dosage. 3. A fluoxetine (Prozac) dosage. 4. A lorazepam (Ativan) dosage.

. Insulin is prescribed based on a sliding scale of fasting blood glucose levels. A Clinical Institute Withdrawal Assessment (CIWA) score assesses symptoms of alcohol withdrawal. Medications that immediately calm the central nervous system (CNS) are prescribed based on this CIWA score. 1. Olanzapine (Zyprexa) is an antipsychotic and would not be used as treatment for alcohol withdrawal. 2. Lithium carbonate (lithium) is a mood stabi- lizer and does not have an immediate, calm- ing effect on the CNS. This drug is not used for alcohol withdrawal. 3. Fluoxetine (Prozac) is an antidepressant and does not have an immediate, calming effect on the CNS. This drug is not used for alco- hol withdrawal. ✅4. A CIWA score is an evaluation of symptoms experienced by a client undergoing alcohol withdrawal. As the score increases, the client's potential for serious complications increases, and CNS depres- sant medications must be administered. These types of medications calm the CNS, decrease elevated blood pressure, and prevent seizures. Lorazepam (Ativan) is a benzodiazepine, which is an anti-anxiety medication that provides an immediate, calming effect on the CNS. Other benzodiazepines, such as chlordiazepoxide (Librium) and diazepam (Valium), also can be used for the symptoms of alcohol withdrawal. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be familiar with several terms, such as "CIWA" and "sliding scale." The test taker also needs to understand the effects of alcohol withdrawal on the CNS necessitating the administration of CNS depressants.

15. A client with a long history of alcoholism recently has been diagnosed with Wernicke- Korsakoff syndrome. Which symptom should the nurse expect to assess? 1. A sudden onset of muscle pain with elevations of creatine phosphokinase. 2. Signs and symptoms of congestive heart failure. 3. Loss of short-term and long-term memory and the use of confabulation. 4. Inflammation of the stomach and gastroesophageal reflux disorder.

1. A sudden onset of muscle pain with elevations of creatine phosphokinase is an indication of alcoholic myopathy, not Wernicke-Korsakoff syndrome. 2. Signs and symptoms of congestive heart failure are indications of alcoholic cardiomyopathy, not Wernicke-Korsakoff syndrome. ✅3.Loss of short-term and long-term memory and the use of confabulation are symptoms of Wernicke-Korsakoff syndrome. The treatment of this syndrome is alcohol abstinence and thiamine replacement. 4. The effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention. These are not symptoms of Wernicke-Korsakoff syndrome. TEST-TAKING HINT: To answer this question cor- rectly, the test taker should note next to each answer choice the specific effects of alcohol on the body characterized by the symptoms described.

22. Which statement is true regarding how the body processes alcohol? 1. Alcohol is absorbed slowly after processing through the liver. 2. Similar to other foods, alcohol must be digested. 3. Rapidity of absorption is influenced by various factors, such as a full stomach. 4. Only moments after consumption, alcohol is excreted.

1. Alcohol is absorbed into the bloodstream rap- idly, not slowly, through the stomach wall before being processed through the liver. 2. In contrast to foods, alcohol does not need to be digested. ✅3. Rapidity of absorption is influenced by various factors. Absorption is delayed when the drink is sipped, rather than gulped; when the stomach contains food, rather than being empty; and when the drink is wine or beer, rather than distilled alcohol. 4. Only moments after alcohol is consumed, it can be found in all tissues, organs, and secretions of the body. It is not immediately excreted. Alcohol still can be found in the urine 12 hours after ingestion. TEST-TAKING HINT: This is essentially a true/false question. Only one answer choice can be true. To answer this question correctly, the test taker either looks for the true statement or eliminates the false statements.

8. A client admitted for chest pain related to cocaine abuse states, "This is nothing but a lit- tle indigestion. What is all the fuss about?" This client is using which defense mechanism? 1. Minimization. 2. Denial. 3. Rationalization. 4. Projection.

1. Clients diagnosed with substance abuse or dependence often minimize problems caused by their addiction. The client in the question is not admitting there is a cardiac problem, rather than minimizing it. The client denies the problem by interpreting it as indigestion ✅2. Denial is used when a client refuses to acknowledge the existence of a real situa- tion or the feelings associated with it. When this client states that chest pain is a "little indigestion," the client is using denial to avoid facing a serious complication of cocaine abuse. 3. Rationalization is an attempt to make excuses or formulate logical reasons to justify unaccept- able feelings or behaviors. This defense is often used by clients diagnosed with substance abuse or dependence, but the situation presented is not reflective of this defense mechanism. 4. When a client attributes feelings or impulses unacceptable to the client to another person, the client is using the defense mechanism of projection. This defense is often used by clients diagnosed with substance abuse or dependence, but the situation described is not reflective of this defense mechanism TEST-TAKING HINT: Minimization and denial are used by substance abusers to avoid looking at problems caused by addiction. To answer this question correctly, the test taker must distin- guish the difference. When using denial, the client refuses to recognize the problem. Using minimization, the client recognizes the problem, but depreciates its effect.

31. A client with a long history of alcohol dependence comes to the emergency department with shortness of breath and an enlarged abdomen. Which complication of alcoholism is this client experiencing, and what is the probable cause? 1. Malnutrition resulting from thiamine deficiency. 2. Ascites resulting from cirrhosis of the liver. 3. Enlarged liver resulting from alcoholic hepatitis. 4. Gastritis resulting from inflammation of the stomach lining.

1. Clients with long histories of alcohol depend- ency often experience malnutrition because they get calories from alcohol rather than nutritious foods. This malnutrition is due to overall deficits in nutritional intake, not just thiamine. This client does not present with signs and symptoms of malnutrition. ✅2. Ascites is a condition in which an excessive amount of serous fluid accumulates in the abdominal cavity, resulting in a protuberant abdomen. This condition occurs in response to portal hypertension caused by cirrhosis of the liver resulting from alcohol dependence. Increased pressure results in the seepage of fluid from the surface of the liver into the abdominal cavity. Pressure of the enlarged abdomen on the diaphragm can cause shortness of breath. 3. An enlarged liver would not manifest as an enlarged abdomen. Anatomically, the liver is located in the right upper quadrant of the abdomen and, if enlarged, can be palpated. Hepatitis can cause liver enlargement, but ascites resulting from cirrhosis of the liver is this client's presenting problem. 4. Gastritis resulting from inflammation of the stomach lining is often a complication of alcohol abuse. The effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention. The client in the question is not complaining of gastric distress. Distention of the abdomen resulting from gastritis would not be significant enough to cause shortness of breath. TEST-TAKING HINT: The test taker needs to be able to distinguish between the various physical compli- cations of chronic alcohol dependence to answer this question correctly. The test taker must read all symptoms carefully to choose the complication that includes the symptoms described

53. The nurse has given a client information on alcoholism recovery. Which client state- ment indicates that learning has occurred? 1. "Once I have detoxed, my recovery is complete." 2. "I understand that the goal of recovery is to decrease my drinking." 3. "I realize that recovery is a lifelong process that comes about in steps." 4. "Al-Anon can assist me in my recovery process."

1. Detoxification from alcohol is the first and easiest step in the recovery process. After detox, the day-to-day recovery process begins. 2. The goal of recovery is abstinence from alcohol, not to decrease the amount of alcohol consumed. ✅3.Recovery is a lifelong process and comes about in steps. Alcoholics Anonymous (AA) is a self-help group that can assist with recovery. Their slogan is "One day at a time." 4. Al-Anon is a support group for spouses and friends of alcoholics. AA is specific to a client diagnosed with alcoholism. TEST-TAKING HINT: This is essentially a true/false question. Only one answer choice can be true. The test taker either should look for the true statement or should eliminate the false state- ments. The test taker also must know the focus of Al-Anon to understand that it is not a support group for clients diagnosed with alcoholism.

32. A client with a long history of alcohol dependence comes to the emergency department with frank hemoptysis. Which life-threatening complication of alcoholism is this client experiencing, and what is the probable cause? 1. Hepatic encephalopathy resulting from the inability of the liver to convert ammonia to urea for excretion. 2. Thrombocytopenia resulting from the inability of the diseased liver to produce adequate amounts of prothrombin and fibrinogen. 3. Hemorrhage of esophageal varices resulting from portal hypertension. 4. Ascites resulting from impaired protein metabolism.

1. Hepatic encephalopathy is a complication of cirrhosis of the liver resulting from chronic alcoholism. It is caused by the inability of the liver to convert ammonia to urea for excretion. The continued increase in serum ammonia results in progressively impaired mental func- tioning, apathy, euphoria or depression, sleep disturbance, increasing confusion, and progres- sion to coma and eventual death. Hemorrhage is not a symptom of this complication. 2. Thrombocytopenia is a complication of cirrhosis of the liver resulting from chronic alcoholism. It is caused by the inability of the diseased liver to produce adequate amounts of prothrombin and fibrinogen. This places the client at risk for hemorrhage, but this client is experiencing the actual problem of frank hemoptysis. ✅3. Esophageal varices are veins in the esophagus that become distended because of excessive pressure from defective blood flow through the cirrhotic liver causing portal hypertension. When pressure increases, these varicosities can rupture, resulting in hemorrhage. The frank hemoptysis experienced by the client indicates ruptured esophageal varices. 4. Ascites occurs in response to portal hyperten- sion caused by cirrhosis of the liver resulting from chronic alcoholism. Increased pressure results in the seepage of fluid from the sur- face of the liver into the abdominal cavity causing an enlarged, protuberant abdomen. Impaired protein metabolism contributes to this complication of cirrhosis. The client's presenting symptoms do not reflect the com- plication of ascites. TEST-TAKING HINT: The test taker must examine the client symptoms described in the question. If the test taker understands the pathophysiology of the physical effects of alcoholism, the correct complication and symptom can be matched easily.

25. A nursing student is reviewing a client's chart. It is noted that the client is exhibiting signs of a drinking pattern in the early alcoholic phase. Which behavior would the stu- dent expect to note? 1. Use of alcohol as a stress reliever. 2. Amnesia that occurs during or immediately after a period of drinking. 3. Total loss of control over drinking behaviors. 4. Continuous intoxication with few periods of sobriety.

1. In the prealcoholic, not early alcoholic, phase, alcohol is used to relieve the everyday stress and tensions of life. ✅2.When an individual experiences blackouts, he or she has entered the early alcoholic phase. Blackouts are brief periods of amnesia that occur during or immediately after a period of drinking. 3. Control is lost and physiological dependence is evident in the crucial, not early alcoholic, phase of alcoholism. 4. An individual is usually intoxicated more often than sober, and emotional and physical disintegration occurs, in the chronic, not early alcoholic, phase of alcoholism TEST-TAKING HINT: The test taker must distin- guish between "blacking out" and "passing out." When a client "passes out," he or she is uncon- scious. This is due to central nervous system depression resulting from the consumption of high amounts of alcohol, a central nervous sys- tem depressant. When a "blackout" is experi- enced, the individual seems to be functioning, but later remembers nothing of the situation.

38. Which is the priority diagnosis for a client experiencing alcohol withdrawal? 1. Ineffective health maintenance. 2. Ineffective coping. 3. Risk for injury. 4. Dysfunctional family processes: alcoholism.

1. Ineffective health maintenance is the inability to identify, manage, or seek out help to maintain health. This is an appropriate nursing diagnosis for many clients diagnosed with substance abuse, not withdrawal. With sub- stance abuse, all activities of life are focused on obtaining and using the substance of abuse, rather than maintaining health. Risk for injury is a higher priority for clients experiencing alcohol withdrawal because of risk for central nervous system (CNS) overstimlation rebound leading to alcohol withdrawal syndrome. 2. Ineffective coping is the inability to form a valid appraisal of stressors, inadequate choices of practiced responses, or inability to use available resources. This is an appropriate nursing diagnosis for many clients diagnosed with substance abuse, not withdrawal. These clients use substances to cope, rather than adaptive behaviors or problem solving. Risk for injury is a higher priority for clients experiencing alcohol withdrawal because of risk for CNS overstimulation rebound leading to alcohol withdrawal syndrome. ✅3. Risk for injury is the result of either internal or external environmental conditions' interacting with the individual's adaptive and defensive resources. It is the priority diagnosis for a client experiencing alcohol withdrawal. Withdrawal of CNS depressants (alcohol) causes a rebound stimula- tion of the CNS, leading to alcohol withdrawal syndrome that may include symptoms of elevated blood pressure, tachycardia, hallucinations, and seizures. 4. Dysfunctional family processes is the chronic disorganization of psychosocial, spiritual, and physiological functions of the family unit that leads to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises. This is an appropriate nursing diagnosis for many clients diagnosed with substance abuse, not withdrawal. Risk for injury is a higher priority for clients experiencing alcohol withdrawal because of risk for CNS overstimulation rebound TEST-TAKING HINT: When prioritizing nursing diagnoses, the test taker always must give priority to client safety. This question asks for a priority diagnosis for alcohol withdrawal. The other diag- noses are appropriate for alcohol abuse, not withdrawal.

52. A client on the substance abuse unit states, "I used to be able to get a 'buzz on' with a few beers. Now it takes a six pack." How should the nurse, in the role of teacher, address this remark? 1. By assessing the client's readiness for learning and reviewing the criteria for substance abuse. 2. By explaining the effects of tolerance and telling the client that this is a sign of alcohol dependence. 3. By presenting the concept of minimization and how this affects a realistic view of the problems precipitated by substance abuse. 4. By confronting the client with the client's use of the defense mechanism of rationalization.

1. It is important always to assess a client's readiness for learning before any teaching. Because this client is experiencing tolerance, which is a symptom of substance dependence rather than abuse, reviewing the criteria for substance abuse is misdirected. ✅2. Tolerance is the need for markedly increased amounts of a substance to achieve intoxication or desired effects. Tolerance is a characteristic of alcohol dependence. Because the client is experi- encing tolerance, the nurse in the role of teacher should present this information. 3. Minimization is a type of thinking in which the significance of an event is minimized or undervalued. There is nothing in the question that indicates that the client is using minimization. 4. Rationalization is a defense mechanism by which an individual attempts to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. There is nothing in the question that indicates that the client is using rationalization. TEST-TAKING HINT: To answer this question cor- rectly, the test taker first needs to recognize and understand the characteristics of tolerance. The test taker then can choose the appropriate teaching priority for the client described in the question.

47. Which nursing intervention is appropriate for a client who has a nursing diagnosis of risk for injury R / T alcohol withdrawal? 1. Monitor fluid intake and output. 2. Provide the client with a quiet room free from environmental stimuli. 3. Teach the client about the effects of alcohol on the body. 4. Empathize with the client but confront denial.

1. Monitoring fluid intake and output is a nurs- ing intervention that does not directly relate to the nursing diagnosis of risk for injury R / T alcohol withdrawal. ✅2. Providing clients who are withdrawing from alcohol with a quiet room free from environmental stimuli is a nursing inter- vention that directly relates to the nursing diagnosis of risk for injury R / T alcohol withdrawal. Alcohol withdrawal is a pattern of physiological responses to the discontinuation of a drug. It is life-threatening, with a mortality rate of 25% caused by a rebound reaction to central nervous system depression leading to increased neurological excitement potentially causing seizures and death. Increased environmental stimuli would exacerbate this problem. Decreasing stimuli would help to avoid injury resulting from alcohol withdrawal. 3. When clients withdraw from alcohol, they are in a health-crisis, life-threatening situation. Teaching would be inappropriate because of increased anxiety generated by this life- threatening situation. 4. When clients withdraw from alcohol, they are in a health-crisis, life-threatening situation. It would be inappropriate to confront denial at this time TEST-TAKING HINT: The test taker must under- stand the critical nature of alcohol withdrawal syndrome to be able to determine the nursing intervention that directly relates to this client's problem. During crisis situations, various nursing interventions, such as teaching the client, can be eliminated immediately because the nurse's focus should be on maintaining client safety and reduc- ing injury.

4. Using the principles of social learing theory, what contributing factor puts a client at risk for alcoholism?. 1. The client's twin sister is an alcoholic. 2. The client was raised in a home where substance use was the norm. 3. The client is from a family that culturally accepts the use of substances. 4. The client experiences pleasure when a substance is used and subsequently driven to repeat the use. 5. Alcohol produces morphine-like substances that are responsible for addiction.

1. Monozygotic (identical) twins have a higher rate for concordance of alcoholism than dizygotic (nonidentical) twins. This is an indication of involvement of a hereditary fac- tor that falls in the category of biological, not sociocultural risk factors for alcoholism. ✅2. Adolescents are more likely to use substances if they have parents who provide a model for substance use. This modeling is a sociocultural factor that influences the risk for alcoholism. ✅3. Factors within an individual's culture help to establish patterns of substance use by molding attitudes and influencing patterns of consumption based on cultural acceptance. Cultural and ethnic influences are sociocultural factors that influence the risk for alcoholism. ✅4. Many substances create a pleasurable experience that encourages the user to repeat use. Conditioning, describes how the intrinsically reinforcing properties of addictive drugs "condition" the individual to seek out and repeat the use of these drugs. Conditioning is a sociocultural factor that influences the risk for alcoholism. 5.Alcohol does produce morphinelike sub- stances in the brain that are linked to alco- holism. These substances are biochemical, not sociocultural, factors that influence the risk for alcoholism. TEST-TAKING HINT: The question requires the test taker to distinguish various factors that influence the risk for alcoholism.

7. A client diagnosed with substance dependence states to the nurse, "My wife causes me to abuse methamphetamines. She uses and expects me to." This client is using which defense mechanism? 1. Rationalization. 2. Denial. 3. Minimization. 4. Projection.

1. Rationalization is an attempt to make excuses or formulate logical reasons to justify unac- ceptable feelings or behaviors. This defense is often used by clients diagnosed with substance abuse or dependence; however, the situation described is not reflective of this defense mechanism. 2. Denial is used when a client refuses to acknowledge the existence of a real situation or the feelings associated with it. This defense is often used by clients diagnosed with substance abuse or dependence; however, the situation described is not reflective of this defense mechanism. 3. Clients diagnosed with substance abuse or dependence often minimize problems caused by their addiction; however, the situation described is not reflective of this defense mechanism. ✅4. When a client attributes feelings or impulses unacceptable to the client to another person, the client is using the defense mechanism of projection. In the question, the client is projecting the responsibility for decisions about his use of methamphetamines to his wife. TEST-TAKING HINT: Rationalization and projection are often confused. The test taker should look for an element of blame or transference of the client's feelings or thoughts to another when a client uses projection. The test taker should look for "excuse making" when rationalization is used.

9. A client who has recently relapsed from alcohol abstinence is seen in the out-patient mental health clinic. The client states, "I don't know what all the fuss is about. Can't I have a few drinks now and then?" Which nursing diagnosis applies to this client? 1. Risk for injury. 2. Risk for violence: self-directed. 3. Ineffective denial. 4. Powerlessness.

1. Risk for injury is defined as when a client is at risk for injury as a result of internal or external environmental conditions' interacting with the individual's adaptive and defensive resources. Nothing is presented in the question to indicate that this client is at risk for injury. If the client were exhibiting signs and symptoms of alcohol withdrawal, the diagnosis of risk for injury would apply. 2. Risk for violence: self-directed is defined as when a client is at risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to self. Nothing is presented in the question to indicate that this client is at risk for self- directed violence. ✅3. Ineffective denial is defined as the conscious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety or fear, leading to the detriment of health. The client in the question is denying the need to continue abstinence from alcohol. 4. Powerlessness is defined as the perception that one's own action would not significantly affect an outcome—a perceived lack of control over a current situation or immediate happening. Nothing is presented in the question to indicate that this client is experiencing power- lessness TEST-TAKING HINT: The test taker must under- stand the behaviors that indicate the use of the defense mechanism of denial to answer this ques- tion correctly. The test taker must use the infor- mation presented in the question to determine the nursing diagnosis for the client. Other nurs- ing diagnoses may apply to clients with specific medical conditions, but the answer must be based on the symptoms presented in the question.

17. A client on an in-patient psychiatric unit is overheard stating, "I blew some snow yesterday while I was out on a pass with my family." What would the nurse expect to assess as a positive finding in this client's urine drug screen? 1. Amphetamines. 2. Cocaine. 3. Barbiturates. 4. Benzodiazepines.

1. Street names for amphetamines include meth, speed, crystal, ice, Adam, ecstasy, Eve, and XTC. ✅2. Street names for cocaine include snow, coke, blow, toot, lady, flake, and crack. 3. Street names for barbiturates include yellow jackets, yellow birds, red devils, blue angels, jelly beans, rainbows, and double trouble. 4. Street names for benzodiazepines include Vs, roaches, dolls, and dollies. TEST-TAKING HINT: The test taker must be able to recognize common names for street drugs to answer this question correctly

43. Which is true about the outcomes of nursing interventions for clients experiencing chemical dependence? 1. Outcomes should be based on guidelines documented in the DSM-IV-TR. 2. Outcomes should be prescribed by NANDA. 3. Outcomes should be tailored to the individual's immediate needs and abilities. 4. Outcomes should return the client to the highest level of wellness.

1. The DSM-IV-TR classifies mental illness and presents guidelines and diagnostic criteria for various mental disorders. It uses a multiaxial system to facilitate comprehensive and sys- tematic evaluation of client problems. The DSM-IV-TR does not set outcomes for nursing interventions for clients experiencing chemical dependence. 2. The North American Nursing Diagnosis Association (NANDA) has formulated an approved list of client problems stated in nursing diagnosis terminology. NANDA does not set outcomes for nursing interventions for clients experiencing chemical dependence. ✅3. An outcome is a specific client expectation related to nursing interventions based on an established nursing diagnosis. Nursing outcomes provide direction for selection of appropriate nursing interventions and evaluation of client progress. Because clients with chemical dependence problems have different strengths, backgrounds, and sup- ports, outcomes of treatment should be tailored to the individual's immediate needs and abilities. This is an individualized process that should not be standardized. 4. Nursing outcomes provide direction for selection of appropriate nursing interventions and evaluation of client progress. These nursing interventions, not outcomes, help a client to return to the highest level of wellness. Outcomes alone, without appropriate inter- ventions, would set expectations only, not assist the client to reach those expectations. TEST-TAKING HINT: To answer this question cor- rectly, the test taker should look for a true state- ment about client outcomes. Understanding the use of the DSM-IV-TR and the NANDA classification of client problems eliminates answers "1" and "2" immediately.

42. Which is the priority diagnosis for a client experiencing alcohol intoxication? 1. Pain. 2. Ineffective denial. 3. Altered coping. 4. Risk for aspiration.

1. The symptoms of alcohol intoxication include lack of inhibition related to sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, unsteady gait, nystagmus, and flushed face, not pain. Because alcohol is a central nervous system depressant, intoxication would decrease, rather than increase, pain. 2. Ineffective denial is the conscious or uncon- scious attempt to disavow knowledge or meaning of an event to reduce anxiety or fear, leading to the detriment of health. This may be an appropriate diagnosis for a client experiencing alcohol intoxication, but of the diagnoses presented, it is not the priority. 3. Ineffective coping is the inability to form a valid appraisal of stressors, inadequate choices of practiced responses, or inability to use available resources. This may be an appropriate diagnosis for a client experiencing alcohol intoxication, but of the diagnoses presented, it is not the priority. ✅4. Alcohol depresses the central nervous system and, with significant intake, can render an individual unconscious. The effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention. These effects of alcohol could lead to aspiration, making this the most life-threatening, priority client problem. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must know the effects of alcohol on the body. When asked for a priority nursing diagnosis, it is important to choose the answer that addresses client safety, in this case aspiration.

24. The nurse is caring for a client on an in-patient substance abuse unit. Because of the client's alcohol abuse, the client has lost family, job, and driver's license. What phase of drinking pattern progression is this client experiencing? 1. Prealcoholic phase. 2. Early alcoholic phase. 3. Crucial phase. 4. Chronic phase.

1. Tolerance to alcohol develops in the prealcoholic phase, but significant losses have not yet occurred. 2. Common behaviors that occur in the early alcoholic phase are sneaking drinks or secret drinking and preoccupation with drinking and maintaining the supply of alcohol. The individual experiences guilt and becomes defensive about drinking. ✅3. In the crucial phase, the client's focus is totally on alcohol. The client is willing to lose everything that was once important in an effort to maintain the addiction. The losses presented in the question are evidence of this crucial phase. 4. Emotional disintegration is evidenced by profound helplessness and self-pity in the chronic phase. Impairment in reality testing may result in psychosis. Clients experience alcohol-related physical problems in almost every system of the body. The client described in this question does not exhibit the extremes of these symptoms. TEST-TAKING HINT: The test taker needs to understand that in the crucial phase of drinking it is common for the individual to have experi- enced the loss of job, marriage, family, friends, and, especially, self-respect.

45. When the nurse is planning relapse prevention strategies for clients diagnosed with substance dependence, which should be the initial nursing approach? 1. Address previously successful coping skills. 2. Encourage rehearsing stressful situations that may lead to relapse. 3. Keep the interventions simple. 4. Provide community resources such as Alcoholics Anonymous (AA).

1.Addressing previously successful coping skills is a good nursing intervention for planning relapse prevention strategies, but it must be in the context of a simple approach. 2. Encouraging rehearsing stressful situations that may lead to relapse is a good nursing intervention for planning relapse prevention strategies, but it must be in the context of a simple approach. ✅3.Because 40% to 50% of clients who abuse substances have mild to moderate cognitive problems while actively using, relapse prevention strategies initially should be approached simply. All interventions should be in the context of simple plan- ning to be fully comprehended by the client. 4. Providing community resources such as AA is a good nursing intervention for planning relapse prevention strategies, but it must be in the context of a simple approach. TEST-TAKING HINT: The keyword "initially" helps the test taker determine the correct answer. All of the interventions are correct for planning relapse prevention strategies, but without a sim- ple approach none of them may be understood effectively by the client.

33. A client with a history of alcoholism is seen in the emergency department 2 days after a binge of excessive alcohol consumption. The nurse suspects pancreatitis. Which symptoms would support the nurse's suspicion? 1. Confusion, loss of recent memory, and confabulation. 2. Elevated creatine phosphokinase and signs and symptoms of congestive heart failure. 3. Paralysis of the ocular muscles, diplopia, and ataxia. 4. Constant, severe epigastric pain; nausea and vomiting; and abdominal distention.

1.Confusion, loss of recent memory, and confabulation are symptoms of Korsakoff's psychosis, not pancreatitis. 2. Elevated creatine phosphokinase and signs and symptoms of congestive heart failure are symptoms of alcoholic cardiomyopathy, not pancreatitis. 3. Paralysis of the ocular muscles, diplopia, and ataxia are symptoms of Wernicke's encephalopathy, not pancreatitis. ✅4. Constant, severe epigastric pain, nausea and vomiting, and abdominal distention are signs of acute pancreatitis, which usually occurs 1 or 2 days after a binge of excessive alcohol consumption. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be able to differentiate the signs and symptoms of various complications of long-term alcohol abuse.

56. A client with a long history of alcohol abuse is showing signs of cognitive deficits. What drug would the nurse recognize as appropriate in assisting with this client's alco- hol recovery? 1. Disulfiram (Antabuse). 2. Naltrexone (ReVia). 3. Lorazepam (Ativan). 4. Methadone (Dolophine).

1.Disulfiram (Antabuse) is a drug that can be administered to individuals who abuse alcohol as a deterrent to drinking. Ingestion of alco- hol when disulfiram is in the body results in a syndrome of symptoms that can produce dis- comfort. Clients must be able to understand the need to avoid all alcohol and any food or over-the-counter medication that contains alcohol. Clients with cognitive deficits would not be candidates for disulfiram (Antabuse) therapy. ✅2. Naltrexone (ReVia) is an opiate antagonist that can decrease some of the reinforcing effects of alcohol and decrease cravings. This would be an appropriate drug for the client described in the question to assist with alcohol recovery. 3. Lorazepam (Ativan) is a central nervous system depressant used as substitution therapy during alcohol withdrawal to decrease the excitation of the central nervous system and prevent complications of alcohol withdrawal. There is no indication in the question that this client is experiencing alcohol withdrawal. 4. Methadone (Dolophine) is used as substitution therapy for opioid, not alcohol, withdrawal TEST-TAKING HINT: The test taker must be familiar with the psychopharmacology used for intoxication and withdrawal of various substances to answer this question correctly. Recognizing that this client has cognitive deficits would elimi- nate "1" immediately. Because the assistance is needed for recovery, not withdrawal, "3" can be eliminated.

46. Family members bring a client to the emergency department after a serious motor vehicle accident caused by the client driving under the influence of cocaine. The client states, "This is my first time using crack." Which nursing intervention would the nurse implement next? 1. Teach the effects of cocaine on the body. 2. Validate this information with family members. 3. Provide community resources related to recovery. 4. Prepare client for admission for detox.

1.In a crisis, as in the situation presented, it is inappropriate to begin any teaching. During crisis, attention and concentration are limited, making learning almost impossible. ✅2. The nurse should validate any information received from this client. Substance abusers tend to minimize or deny substance use. Duration of use and quantity of cocaine used must be assessed to interpret accurately the client's risk for cocaine overdose. 3. Providing community resources related to recovery would be appropriate only if the client is actively seeking help for cocaine abuse. In this crisis situation, the nurse does not know if this client is motivated to change, so it would be premature to offer community resources. 4. Because there is no physical dependency related to cocaine abuse, there would be no need to admit this client for detoxification. TEST-TAKING HINT: To choose the correct answer to this question, the test taker must focus on the client's current situation. This recognition would eliminate answers "1" and "3." Understanding that cocaine has no physical withdrawal symp- toms eliminates "4."

44. A client who is exhibiting signs and symptoms of alcohol withdrawal is admitted to the substance abuse unit for detox. One of the nursing diagnoses for this client is ineffective health maintenance. Which is a long-term outcome for this diagnosis? 1. The client will agree to attend nutritional counseling sessions. 2. The client's medical tests will show a reduced incidence of medical complications related to substance abuse within 6 months. 3. The client will identify three effects of alcohol on the body by day 2 of hospitalization. 4. The client will remain free from injury while withdrawing from alcohol.

1.That the client will agree to attend nutritional counseling sessions is a short-term outcome for the nursing diagnosis of ineffective health maintenance. This outcome also is stated incorrectly because it does not contain a measurable timeframe. ✅2.A long-term outcome for the nursing diagnosis of ineffective health maintenance for the client described is that the client's medical tests will show a reduced incidence of medical complications related to substance abuse within 6 months. 3. That the client will identify three effects of alcohol on the body by day 2 of hospitalization is a short-term outcome for the nursing diagnosis of ineffective health maintenance. 4. That the client will remain free from injury while withdrawing from alcohol is not an out- come that relates to the nursing diagnosis of ineffective health maintenance. This outcome would relate to the nursing diagnosis of potential for injury related to alcohol withdrawal. TEST-TAKING HINT: The test taker should focus on two key concepts in this question—first the nursing diagnosis being addressed and then the long-term nature of the outcome. Because answer "2" has no timeframe incorporated in the outcome and cannot be measured, it can be elim- inated immediately.

1. Which individual would have the lowest potential for alcohol dependency? 1. A 32-year-old male Finn. 2. A 20-year-old Asian woman. 3. A 60-year-old Irishman. 4. An 18-year-old Native American.

1.The incidence of alcohol dependence is higher among northern Europeans than among southern Europeans. The Finns and the Irish use excessive alcohol consumption to release aggression and deal with seasonal affective disorder caused by minimal sunlight in winter months. ✅2. Incidence of alcohol dependence among Asians is low. This may be the result of a possible genetic intolerance to alcohol. 3. The incidence of alcohol dependence is higher among northern Europeans than among southern Europeans. Besides using alcohol to deal with aggression and seasonal affective disorder caused by minimal sunlight in winter months, there is a genetic component that predisposes the Irish to alcoholism. 4. A high incidence of alcohol dependency has been documented within the Native American culture. Death rates from alcoholism among Native Americans are more than seven times the national average. TEST-TAKING HINT: The question requires that the test taker know that there are cultural differences in the prevalence of alcoholism. These differences are evidence of a genetic predisposition to alcoholism.

6. From a biochemical perspective, what factor is implicated in the predisposition to the abuse of substances? 1. Children of alcoholics are four times more likely than other children to be alcoholics. 2. Animal tests show that injections of the morphine-like substance that is produced by alcohol results in addicted test animals. 3. Fixation in the oral stage of psychosocial development can be the cause of substance abuse disorders. 4. Depressive response cycles and antisocial personality disorders are associated with substance abuse disorders.

1.This statement of substance abuse causation is from a genetic, not biochemical, perspective. ✅2.This true statement of substance abuse causation is from a biochemical perspective 3. This statement of substance abuse causation is from a developmental, not biochemical, perspective. 4. This statement of substance abuse causation is from a personality type, not biochemical, perspective. TEST-TAKING HINT: The "morphine-like sub- stance" presented in the answer choice should be a clue to the biochemical nature of this perspec- tive and should lead the test taker to choose the correct answer.

54. Which of the following are reasons for the success of 12-step programs such as Alcoholics Anonymous (AA)? Select all that apply. 1. 12-step programs break down denial in an atmosphere of support. 2. 12-step programs give clients feelings of belonging to a community. 3. 12-step programs help clients recognize the power they have over their addiction. 4. 12-step programs provide experts in the field of chemical dependence to increase the addicted client's knowledge of the effects of addiction. 5. 12-step programs provide sponsors that enable clients to fit back into social settings.

A 12-step program is designed to help an individual refrain from addictive behaviors and foster individual growth and change. ✅1. A 12-step program helps break down denial in an atmosphere of support, understanding, and acceptance. Clients work with sponsors within the support group to accomplish this goal. ✅2. A 12-step program helps clients establish a relationship between a person's feelings of belonging and treatment outcomes. When clients feel socially involved with others in the support group, they have a higher rate of continuation of treatment and lower relapse rates. 3. The first step of the "12 Steps of Alcoholics" is to admit powerlessness over alcohol 4. A 12-step program is a self-help organization. Individuals are helped to maintain sobriety by the assistance of peers with similar problems, not experts in the field. 5. Sponsors that are provided by a 12-step program assist fellow alcoholics with individual growth and change. Change must be the responsibility of the alcoholic and not imposed by the sponsor. Social settings, friends, and lifestyles need to be modified to achieve sobriety and avoid relapse. TEST-TAKING HINT: The test taker must under- stand the principles of 12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) to choose appropriate reasons for the success of these programs.

9. The nurse is discussing the principles of 12-step programs for recovery with a client. Which statement is consistent with the principles of 12-step programs? A) The client will need to abstain from all substances for successful recovery. B) Once sober, the person can safely return to life as it was before becoming addicted. C) The prognosis for recovery is enhanced with the aid of maintenance medications. D) Recovery requires adherence to a plan of achieving long-term goals.

Ans: A Feedback: Alcoholics Anonymous (AA) 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. Key slogans reflect the ideas in the 12 steps, such as ìone day at a timeî (approach sobriety one day at a time), ìeasy does itî (don't get frenzied about daily life and problems), and ìlet go and let Godî (turn your life over to a higher power).

23. The nurse is coleading a family therapy group with a client addicted to alcohol. Which statement made by the wife indicates the need for additional education regarding alcoholism as a family illness? A) "I have to call in sick for my husband when he is too hung over to go to work." B) "Last time he got arrested, I just let him sit in jail." C) "We have separated our finances so that I will not go broke." D) "I take my kids with me to Al-anon meetings every week."

Ans: A Feedback: Alcoholism (and other substance abuse) often is called a family illness. One type of codependent behavior is called enabling, which is a behavior that seems helpful on the surface but actually perpetuates the substance use. Family members should be referred to Al-anon 12-step self-help groups.

25. A client calls the emergency department of the local hospital reporting that after 16 years of heavy drinking, he is tired and wants to quit ìcold turkey.î What would be the best response by the nurse? A) "It is not safe to stop drinking suddenly without medicine." B) "You sound really motivated. Come in and we will help you find a treatment center." C) "After a few days of rest, you should feel much better as long as you do not drink anything." D) "You will likely feel anxious and get a severe headache. Treat these symptoms with acetaminophen and rest, and come in if they do not get better in 3 to 5 days."

Ans: A Feedback: Because alcohol withdrawal can be life threatening, detoxification needs to be accomplished under medical supervision. If the client's withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be treated safely at home. For more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting. Some psychiatric units also admit clients for detoxification, but this is less common.

34. A client is readmitted to the detox unit for the fourth time in 3 years. The nurse states in the morning report, ìNot again! Why should we keep trying to help this guy? He obviously doesn't want it.î What does this statement reflect? A) The nurse lacks the self-awareness to work effectively with this addicted client. B) The nurse understands the cycle of remission and relapse characteristic of addiction. C) The nurse has repressed negative emotions from past experiences with addiction. D) The nurse is trying to conceal his or her own addictions.

Ans: A Feedback: Many clients experience periodic relapses. For some, being sober is a lifelong struggle. The nurse may become cynical or pessimistic when clients return for multiple attempts at substance use treatment. Such thoughts as ìhe deserves health problems if he keeps drinkingî or ìshe should expect to get hepatitis or HIV infection if she keeps doing intravenous drugsî are signs that the nurse has some self-awareness problems that prevent him or her from working effectively with clients and their families. It is not appropriate to assume that the nurse is trying to conceal his or her own addictions.

3. Which of the following groups could benefit most from prevention programs? A) Children, prior to first use B) Adults who have already engaged in substance abuse C) Older adults D) Infants

Ans: A Feedback: Poor outcomes have been associated with an earlier age at onset and longer periods of substance use. 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 who have already engaged in substance abuse will not benefit as greatly from prevention programs as will children. Older adults will not benefit as greatly from prevention programs as will children. Infants will not benefit from prevention programs as they do not have self-efficacy.

5. The nurse is assessing a client's risk factors for developing a substance abuse disorder. Which family characteristics would the nurse identify as a significant risk factor? A) One parent who is an alcoholic B) Parents who practiced strict discipline C) Overprotective parents D) Being raised in an urban area

Ans: A Feedback: The strongest indication of risk factors comes from studies that indicate children of alcoholic parents are four times as likely to develop alcoholism that of nonalcoholic parents. Some theorists also believe that inconsistency in the parent's behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse. Others hypothesize that even children who abhorred their family lives are likely to abuse substances as adults because they lack adaptive coping skills and cannot form successful relationships. Urban areas where drugs and alcohol are readily available also have high crime rates, high unemployment, and substandard school systems that contribute to high rates of cocaine and opioid use and low rates of recovery.

18. A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen in the emergency department. The client is oriented but is tremulous, weak, and sweaty and has some gastrointestinal (GI) symptoms. Which of the following is typical of these symptoms? A) Alcohol withdrawal syndrome B) Continuing intoxication C) Delirium tremens D) WernickeñKorsakoff syndrome

Ans: A Feedback: Withdrawal from alcohol produces shakiness, weakness, diaphoresis, and GI symptoms. These are not symptoms of continuing intoxication. Delirium tremens produce hypertension, delusions, hallucinations, and agitated behavior. Wernicke-Korsakoff syndrome is a type of dementia caused by long-term, excessive alcohol intake that results in a chronic thiamine or vitamin B6 deficiency.

2. Which statements are important reasons for why the problem of substance abuse must be addressed? Select all that apply. A) Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs. B) Chemical abuse results in increased violence. C) Drug abuse costs business and industry an estimated $102 billion annually. D) Alcohol abuse is a too frequent cause of or contributor to death. E) Substance abuse is decreasing.

Ans: A, B, C, D Feedback: Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs. Chemical abuse results in increased violence. Drug abuse costs business and industry an estimated $102 billion annually. Alcohol abuse is a too frequent cause of or contributor to death. Substance use/abuse and related disorders are a national health problem.

35. Which reasons make it necessary for the nurse to examine his or her beliefs and attitudes about substance abuse? Select all that apply. A) The nurse may be overly harsh and critical of the client. B) The nurse may unknowingly act out old family roles and engage in enabling behavior. C) The nurse or close friends and family of the nurse may abuse substances. D) The nurse may have different attitudes about various substances of abuse. E) The nurse is not likely to have had any experience with substance abuse.

Ans: A, B, C, D Feedback: The nurse must examine his or her beliefs and attitudes about substance abuse. A history of substance abuse in the nurse's family can strongly influence his or her interaction with clients. The nurse may be overly harsh and critical. Conversely, the nurse may unknowingly act out old family roles and engage in enabling behavior. Examining one's own substance use or use by close friends and family may be difficult and unpleasant but is necessary if the nurse is to have therapeutic relationships with clients. The nurse also might have different attitudes about various substances of abuse. Health-care professionals also have higher rates of alcoholism than the general population. With the pervasive nature of substance abuse nationally, odds are great that nurses and other health professionals have been affected by substance abuse in their lives.

31. Which are general warning signs of substance abuse that a nurse should be alert for in coworkers? Select all that apply. A) Poor work performance B) Frequent absenteeism C) Unusual behavior D) Slurred speech E) Isolation from peers F) Substance abuse is not a problem in health professionals

Ans: A, B, C, D, E Feedback: General warning signs of abuse include poor work performance, frequent absenteeism, unusual behavior, slurred speech, and isolation from peers. Physicians, dentists, and nurses have far higher rates of dependence on controlled substances, than other professionals of comparable educational achievement. One reason is thought to be the ease of obtaining controlled substances. Health-care professionals also have higher rates of alcoholism than the general population.

27. The nurse is coleading a family therapy group for clients and families of drug-addicted individuals. The family of a cocaine addict is angry and cannot understand why the client cannot just stop using. The nurse guides the group to discuss their understanding of the nature of addiction. Which statements would the nurse identify as an accurate understanding of the nature of addiction? Select all that apply. A) It is a medical illness that is progressive. B) The client will eventually be cured. C) Relapses and remissions are part of the illness. D) Clients can learn to get control over the substance.

Ans: A, C Feedback: Alcoholism (and other substance abuse) often is called a family illness. All those who have a close relationship with a person who abuses substances suffer emotional, social, and sometimes physical anguish. Client and family members need facts about the substance, its effects, and recovery. The nurse must dispel myths and misconceptions such as, ìIt's a matter of will power,î ìI can't be an alcoholic if I only drink beer or if I only drink on weekends,î ìI can learn to use drugs socially,î or ìI'm okay now; I could handle using once in a while.î

10. Which characteristic of the 12-step program distinguishes it from other programs? A) The philosophy that it is possible to reduce the use of substances without abstaining. B) It is a self-help group that does not necessarily use health professionals as leaders. C) Persons who use this program are independent in their sobriety. D) Infrequent attendance is usually successful.

Ans: B Feedback: Alcoholics Anonymous (AA) 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.

32. The nurse is working in an intensive care unit and observes that some clients do not respond to injections of diazepam (Valium) when the injections are given by a particular nurse. This nurse returns from lunch exhibiting slurred speech and euphoria. Which is the best action for the nurse to take? A) Ask other nurses if they have noticed anything unusual. B) Call the manager and report the observations. C) Observe the nurse as injections are prepared and administered. D) Tell the nurse, ìI know you've been stealing Valium.î

Ans: B Feedback: Any suspicions should be communicated to someone in a supervisory position so that effective action can be taken.

33. A peer reports for work looking unkempt and disheveled. Her movements are uncoordinated, and her breath smells like mouthwash. Another nurse suspects this peer is intoxicated. What should be the action of the nurse who suspects that a peer is intoxicated? A) Immediately call the supervisor to report the peer's behavior. B) Ask the peer if she feels alright and express concern. C) Give the peer some information about the hospital's employee assistance program. D) Ignore the situation until someone else validates the observations.

Ans: B Feedback: Client safety is a priority; the impaired nurse should not be caring for clients. After client safety is ensured, the nurse should call the supervisor to handle the situation. It is not the nurse's responsibility to give out information on the hospital's employee assistance program. It is not appropriate to ignore the situation.

14. A client is being discharged from treatment for addiction to cocaine. Which statement made by the client would cause the most concern for the nurse? A) "I am going to take up a new hobby. It's time to start something new." B) "I can still hang out with my old friends. I am just not going to use." C) "I'm not very comfortable with being alone yet." D) "Shooting baskets helps me not think about getting high."

Ans: B Feedback: Clients are likely to have exercised poor judgment. They may still believe they can control the substance use. The nurse can help clients to find ways to relieve stress or anxiety that do not involve substance use. Relaxing, exercising, listening to music, or engaging in activities may be effective. Clients also may need to develop new social activities or leisure pursuits if most of their friends or habits of socializing involved the use of substances. Acknowledging difficulties shows insight into the changes needed for recovery. Assuming that old friends will not be a relapse trigger shows a lack of understanding of the relapse dynamics associated with former leisure activities.

7. The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse that his relationship with the client was codependent and enabling. Which is an example of codependent behavior? A) The friend called Alcoholics Anonymous when the client expressed a need to stop drinking. B) The friend called the client every night to make sure he got home safely and went looking for him if he was not at home. C) The friend confronted the client on the effect of his drinking on their relationship. D) The friend refused to go out drinking with the client to celebrate the client's birthday.

Ans: B Feedback: Codependent behavior appears helpful on the surface but actually prolongs the drinking behavior. The other choices are not examples of codependent behavior.

1. A community health nurse is planning a substance abuse prevention program. Which group would be the best target audience for the nurse to plan a program? A) Teenagers in a high school health class B) School-age children in an after-school program C) Parents attending a parentñteacher association meeting D) Elementary school teachers and counselors

Ans: B Feedback: Forty-three percent of all Americans have been exposed to alcoholism in their families. Children of alcoholics are four times more likely than the general population to develop problems with alcohol. Many adult people in treatment programs as adults report having had their first drink of alcohol as a young child, when they were younger than age 10. With the increasing rates of use being reported among young people today, this problem could spiral out of control unless great strides can be made through programs for prevention, early detection, and effective treatment.

17. A nurse is exploring treatment options with a client addicted to heroin. Which information regarding the use of methadone is important for the nurse to include? A) Unlike heroin, methadone is nonaddicting. B) Methadone will meet the physical need for opiates without producing cravings for more. C) Methadone will produce a high similar to heroin. D) People taking methadone run the same risks associated with IV drug use as those taking heroin.

Ans: B Feedback: Methadone, a potent synthetic opiate, is used as a substitute for heroin in some maintenance programs. The client takes one daily dose of methadone, which meets the physical need for opiates but does not produce cravings for more. Methadone does not produce the high associated with heroin. The client has essentially substituted his or her addiction to heroin for an addiction to methadone; however, methadone is safer because it is legal, controlled by a physician, and available in tablet form. The client avoids the risks of intravenous drug use, the high cost of heroin (which often leads to criminal acts), and the questionable content of street drugs.

8. When interviewing the family members of a client being treated for substance abuse problems, which behavior would alert the nurse to the possibility of codependency? A) Being flexible but angry B) Blaming themselves for the family's problems C) Expressing thoughts and feelings openly D) Taking pleasure in self-accomplishments

Ans: B Feedback: Self-blame is an example of maladaptive coping or codependent behavior. The other choices do not correlate with codependency behaviors.

21. A client is readmitted to the substance abuse program for the second time in 6 months for alcohol abuse. On admission, he tells the nurse, "I am so ashamed." What should the nurse reply? A) "I really thought you would make it." B) "Tell me what has happened since your last admission." C) "You have nothing to be ashamed of." D) "Why did you start drinking again?"

Ans: B Feedback: This is a therapeutic communication technique designed to help the client talk about himself and his current situation.

30. A nurse suspects a coworker is signing out narcotics for clients and is using them herself. Which action should be taken by the nurse who has these suspicions? A) Ignore suspicions and leave it to the supervisor to intervene. B) Report the observations to the supervisor. C) Follow behind the coworker to ensure client comfort and safety. D) Confront the coworker about suspicions.

Ans: B Feedback: Nurses have an ethical responsibility to report suspicious behavior to a supervisor and, in some states, a legal obligation as defined in the state's nurse practice act. Nurses should not try to handle such situations alone by warning the coworker; this often just allows the coworker to continue to abuse the substance without suffering any repercussions.

24. A nurse is working with a couple seeking counseling for marital discord. The history indicates the husband was treated for substance abuse 4 years ago and attends AA meetings occasionally. Which statement made by the recovering husband should alert the nurse for the need for further education? A) "I still need to go to AA meetings even though I have been sober for years." B) "After all these years, I just don't have the will power to stop if I started using again." C) "She gets upset when I hang out with my old buddies on the weekends." D)"I wish I could be able to handle just one beer with dinner."

Ans: C Feedback: Family members and friends should be aware that clients who begin to revert to old behaviors, return to substance-using acquaintances, or believe they can ìhandle myself nowî are at high risk for relapse, and loved ones need to take action. The nurse must dispel myths and misconceptions such as, "It's a matter of will power" "I can't be an alcoholic if I only drink beer or if I only drink on weekends," "I can learn to use drugs socially," or "I'm okay now; I could handle using once in a while."

12. The nurse is assessing the drinking history of a client being admitted for alcohol abuse. Which statement would the nurse expect the client to make? A) "I really need some help. My drinking is tearing my family apart." B) "I have tried so many times to stop drinking. It is so hard." C) "I don't really have a problem with alcohol. I've just been having a streak of bad luck lately." D) "I have no intention to stop drinking. I like the way it makes me feel."

Ans: C Feedback: Substance use typically includes the use of defense mechanisms, especially denial. Clients may deny directly having any problems or may minimize the extent of problems or actual substance use. During assessment of thought process and content, clients are likely to minimize their substance use, blame others for their problems, and rationalize their behavior. They may believe that they could quit ìon their ownî if they wanted to, and they continue to deny or minimize the extent of the problem. Upon admission, the nurse would not expect the client have the insight to know how badly help is needed, or to express powerlessness over alcohol. The client would have some motivation for treatment if admission was underway. Often the motivation is external, such as pressure from family or employers.

29. A client will be taking disulfiram (Antabuse) after discharge from an alcohol treatment program. Which statement would indicate that teaching has been effective? A) ìAntabuse is safe to take with any over-the-counter cold medication.î B) ìAntabuse will block my cravings for alcohol, so I'll have less desire to drink.î C) ìDrinking alcohol while taking Antabuse can cause dangerous symptoms.î D) ìIf I drink while taking Antabuse, it will make me vomit before the alcohol affects me.î

Ans: C Feedback: Taking alcohol in any form while taking Antabuse causes a severe adverse reaction. Antabuse is not safe to take with OTC medications. It does not block cravings for alcohol. Antabuse does not restrict the effect of alcohol on the body.

15. A client is being discharged on disulfiram (Antabuse). Which instruction for Antabuse should the client receive? A) Take disulfiram with food to avoid stomach upset. B) Skip the daily dose of disulfiram on days when consumption of alcoholic beverages is likely. C) Read products labels carefully to avoid all products containing alcohol. D) Disulfiram will prevent the desire to drink alcoholic beverages.

Ans: C Feedback: The client must avoid a wide variety of products that contain alcohol such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla and other extracts. The client must read product labels carefully, because any product containing alcohol can produce symptoms. Ingestion of alcohol may cause unpleasant symptoms for 1 to 2 weeks after the last dose of disulfiram.

11. Which slogans would be used in a 12-step program? Select all that apply. A) "Pull yourself together." B) "Get control of your problem." C) "One day at a time." D) "Easy does it." E) "Let go and let God."

Ans: C, D, E Feedback: Before the illness of addiction was fully understood, most of the society and even the medical community viewed chemical dependency as a personal problem; the user was advised to ìpull yourself togetherî and ìget control of your problem.î Key slogans in AA reflect the ideas in the 12 steps, such as ìOne day at a time" (approach sobriety one day at a time), "easy does itî (don't get frenzied about daily life and problems, and "let go and let God" (turn your life over to a higher power).

4. Which of the following neurochemical influences is a probable cause of substance abuse? A) Imbalances of serotonin and norepinephrine in the brain B) Inhibition of GABA in the brain C) Excessive serotonin activity in the CNS D) Stimulation of dopamine pathways in the brain

Ans: D Feedback: Neurochemical influences on substance use patterns have been studied primarily in animal research (Jaffe & Anthony, 2005). The ingestion of mood-altering substances stimulates dopamine pathways in the limbic system, which produces pleasant feelings or a "high" that is a reinforcing, or positive, experience.

13. A client in treatment for drug abuse makes the statement, "I am a winner. You all are the losers because you can't beat this on your own." What common characteristic of persons addicted to drugs is revealed in this statement? A) Realistic understanding of successful recovery of drug addiction B) Indication of an underlying personality disorder C) Brain damages resulting from chronic drug use D) Defending against a negative self-concept

Ans: D Feedback: Clients generally have low self-esteem, which they may express directly or to cover with grandiose behavior. They do not feel adequate to cope with life and stress without the substance and often are uncomfortable around others when not using. They often have difficulty identifying and expressing true feelings.

16. The client asks the nurse, ìWhat will happen if I drink while taking Antabuse?î What should be the nurse's reply? A) "You will not want to drink while taking Antabuse. It reduces the cravings." B) "You will not get any effect from the alcohol you drink." C) "Antabuse will reverse the effects of alcohol." D) "You will experience a severe reaction, including a throbbing headache and vomiting."

Ans: D Feedback: Disulfiram (Antabuse) may be prescribed to help deter clients from drinking. If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, sweating, nausea, and vomiting. In severe cases, severe hypotension, confusion, coma, and even death may result.

28. The wife of a client who is alcoholic asks the nurse how to respond to him in a helpful way when he is disruptive in family life. Which is the nurse's best response? A) ìHelp him avoid embarrassment by supporting him when he makes excuses for failing to meet obligations.î B) ìInclude him in family outings even when he is drinking.î C) ìSearch the house regularly for alcohol.î D) ìTry to maintain a normal home environment for yourself and the children.î

Ans: D Feedback: Focusing on self and family members is the first step in breaking codependent behavior. Answer choices A, B, and C would not be the best response.

26. An unconscious client is admitted to the emergency department after a motor vehicle accident. The client's blood alcohol level upon admission was 1.7. The client's family soon arrives, reporting that the client is an uncle who is visiting from out of town. They cannot give much more history other than that he is a ìsocial drinker.î After being transported to the unit, the client starts sweating and has elevated vital signs. What information should the nurse request of the family? A) Who is the next of kin? B) For what occasion is the uncle visiting from out of town? C) Does the uncle have a history of any sort of anxiety disorder? D) Are there other indications that the client may be a heavy drinker?

Ans: D Feedback: It is important to assess the situation thoroughly and since the client is unconscious, he cannot communicate what is happening to the staff. The best chance for the staff to understand what is going on would be to inquire further of the relatives. If the client is experiencing withdrawal, detoxification needs to be initiated immediately under medical supervision. Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or deliriumócalled delirium tremens (DTs). Alcohol withdrawal usually peaks on the second day and is over in about 5 days.

22. A client has been admitted to the inpatient unit after using inhalants recently. Which is an antidote to treat inhalant toxicity? A)Ativan B)Narcan C)Antabuse D)There is no antidote

Ans: D Feedback: There is no antidote or specific medication to treat inhalant toxicity. Ativan, Narcan, and Antabuse are not used to treat inhalant toxicity.

5. Which nursing statement focuses on the personality factors that are implicated in the predisposition to the abuse of substances? 1. "Hereditary factors are involved in the development of substance abuse disorders." 2. "Alcohol produces morphine-like substances in the brain that are responsible for alcohol abuse." 3. "A punitive superego is at the root of substance abuse." 4. "A tendency toward addictive behaviors increases as low self-esteem, passivity, and an inability to relax or defer gratification increase."

Substance abuse also has been associated with antisocial personality and depressive response personality styles. 1. This statement is related to the genetic, not personality, factors that predispose individuals to substance abuse problems. 2. This statement is related to the biochemical, not personality, factors that predispose individuals to substance abuse problems. 3. This statement is related to the developmental , not personality, factors that predispose individuals to substance abuse problems. ✅4. This true statement is related to the personality factors that predispose individuals to substance abuse problems. TEST-TAKING HINT: To help differentiate among the various factors that predispose individuals to substance abuse, the test taker should try noting the category of factors next to the answer choices.

10. Which assessment data should the nurse gather when confirming a diagnosis of sub- stance dependence? 1. Continued substance use despite recurrent interpersonal problems. 2. Recurrent, substance-related legal problems. 3. Recurrent substance use resulting in failure to fulfill major role obligations. 4. A need for markedly increased amounts of the substance to achieve desired effect.

Substance abuse is described as a maladaptive pattern of substance use leading to clinically significant impairment or distress. Clients experiencing substance dependence may have all the symptoms of substance abuse. What distinguished dependence from abuse is increasing tolerance and withdrawal symptoms. 1. Continued substance use despite recurrent interpersonal problems is listed in the DSM- IV-TR as a symptom of substance abuse, not substance dependence. 2. Recurrent, substance-related legal problems is listed in the DSM-IV-TR as a symptom of substance abuse, not substance dependence. 3. Recurrent substance use resulting in failure to fulfill major role obligations is listed in the DSM-IV-TR as a symptom of substance abuse, not substance dependence. ✅4. A need for markedly increased amounts of a substance to achieve desired effect is evidence of tolerance. This is listed in the DSM-IV-TR as a symptom of substance dependence. A cluster of cognitive, behav- ioral, and physiological symptoms evidences physical dependence on a substance. Continued use of the substance is required to prevent the experience of unpleasant effects characteristic of the withdrawal syndrome associated with that particular substance. TEST-TAKING HINT: The question requires that the test taker be able to distinguish between the signs and symptoms of substance abuse and sub- stance dependence and recognize tolerance as a sign of substance dependence.

37. A client is admitted to the emergency department and is tested for blood alcohol level (BAL). The client has a BAL of 0.10 g/dL. What is an accurate assessment of this lab value? 1. The client is within the legal limits of BAL. 2. The client is assessed as legally intoxicated. 3. The client would be considered intoxicated depending on state law requirements. 4. The client must perform other psychomotor tests to determine intoxication.

The federally imposed standard of intoxication isa blood alcohol level (BAL) of 0.08 g/dL or greater. 1. Because the client's BAL is 0.10 g/dL, which is greater than the 0.08 g/dL legal limit, the client is assessed as legally intoxicated. ✅2. With a BAL of 0.10, which is greater than the 0.08 g/dL legal limit, the client is con- sidered legally intoxicated. 3. All states must conform to the federally imposed BAL level limit of 0.08 g/dL for intoxication. Individual state law would not be a consideration. 4. Intoxication is determined by a BAL of 0.08 g/dL or greater. No other psychomotor tests are necessary. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must know the legal BAL for intoxication (0.08 g/dL), and that this level is federally mandated.

23. Which behavior reflects the prealcoholic phase of drinking progression? 1. Alcohol is used to relieve the stress of life situations, leading to the development of tolerance. 2. Alcohol is no longer a source of pleasure, but rather a drug that is required by the individual. Blackouts are experienced. 3. Control is lost, and physiological dependence is evident. 4. The individual is usually intoxicated more than sober, and emotional and physical disintegration occur.

There are four phases through which an alco- holic's pattern of drinking progresses: the preal- coholic phase, early alcoholic phase, crucial phase, and chronic phase. ✅1. In the prealcoholic phase, alcohol is used to relieve the everyday stress and tensions of life. 2. The early alcoholic phase begins with black-outs. Alcohol has become required rather than a source of pleasure or relief for the individual. 3. Control is lost and physiological dependence is evident in the crucial phase of drinking pattern progression. 4. In the chronic phase, the individual is usually intoxicated more often than sober, and TEST-TAKING HINT: The test taker must understand the phases of an alcoholic's drinking pattern progression to recognize characteristics of each phase

50. Which intervention takes priority when dealing with a client experiencing Wernicke- Korsakoff syndrome? 1. Monitor parenteral vitamin B1. 2. Increase fluid intake. 3. Provide prenatal vitamins. 4. Encourage foods high in vitamin C.

Wernicke's encephalopathy and Korsakoff's psychosis are two disorders that occur as a direct result of long-term alcoholism and are considered together in the United States as Wernicke- Korsakoff syndrome. ✅1. Intravenous thiamine, vitamin B1, is the treatment of choice and a priority when a client is experiencing the life-threatening complication of Wernicke-Korsakoff syn- drome. This syndrome is caused by a thiamine deficiency resulting from poor intake of vitamin B1 and poor absorption of this vitamin. 2. Increasing fluid intake would not be an intervention indicated or prioritized for a client diagnosed with Wernicke-Korsakoff syndrome. 3. A client diagnosed with long-term alcoholism is probably experiencing nutritional deficits. These deficits occur because caloric intake is supplied by alcohol rather than nutritious foods. Prenatal vitamins do contain the B complex, including B1, but not in sufficient amounts to counteract the effects of Wernicke-Korsakoff syndrome. 4. Encouraging foods high in vitamin C would not be an intervention indicated or prioritized for a client diagnosed with Wernicke- Korsakoff syndrome. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must know the cause of Wernicke-Korsakoff syndrome and not confuse overall nutritional deficits with the specific thi- amine deficiency that leads to Wernicke- Korsakoff syndrome in clients diagnosed with alcoholism.

11. While performing an intake interview, the nurse learns that the client drinks to avoid early morning "shakes." The nurse recognizes this behavior as characteristic of which assessment? 1. Substance abuse. 2. Substance dependence. 3. Substance intoxication. 4. Delirium tremens.

Withdrawal symptoms are characteristic of the diagnosis of substance dependence. 1. Withdrawal symptoms are not included in the DSM-IV-TR criteria for substance abuse. ✅2. The criteria for substance dependence include the evidence of withdrawal symptoms. Tremors are one of the withdrawal symptoms that may be experienced with alcohol dependence. Withdrawal symptoms are characteristic for the specific substance or when the same or similar substance is taken to relieve or avoid these symptoms, which is the case in the situation described in the question. 3. Substance intoxication is defined as the development of a reversible substance-specific syndrome caused by the recent ingestion of a substance. Behavioral changes are attributed to the physiological effects of the substance ingested on the central nervous system. 4. Delirium tremens is a dramatic complication of alcoholism. The onset is sudden, and the client presents with any or all of the following symptoms: restlessness, irritability, confusion, tremulousness, and insomnia leading to hallucinations and generalized convulsions. This acute complication is not described in the question. TEST-TAKING HINT: The question requires that the test taker recognize tremors as a withdrawal symptom and that these are a sign of substance dependence.

39. A client with a long history of alcoholism has been recently diagnosed with alcoholic cardiomyopathy. Which nursing diagnosis would take priority? 1. Altered perfusion R / T effects of alcoholism AEB decreased oxygen saturations. 2. Altered coping R / T powerlessness AEB chronic substance abuse. 3. Risk for injury R / T congestive heart failure. 4. Activity intolerance R / T decreased perfusion.

✅. 1. Alcoholic cardiomyopathy results from the effects of alcohol on the heart by the accumulation of lipids' causing the heart to enlarge and weaken, leading to con- gestive heart failure. Symptoms include decreased exercise tolerance, tachycardia, dyspnea, edema, palpitations, and nonproductive cough. Altered perfusion related to palpitations as evidenced by decreased oxygen saturations would address and prioritize these client problems. 2. Although most clients experiencing alcohol abuse use alcohol to cope with stressors and can feel powerless, this nursing diagnosis does not address the client's problem of alcoholic cardiomyopathy. 3. This nursing diagnosis is incorrectly written. You cannot include a medical diagnosis within a nursing diagnosis. Nursing diagnoses address client problems that are within the nurse's scope of practice. Also, the risk for injury does not address the alcoholic cardiomyopathy presented in the question. 4. Activity intolerance is a symptom of alcoholic cardiomyopathy. Altered perfusion is prioritized because if this can be resolved, the activity intolerance also would be corrected. TEST-TAKING HINT: When prioritizing nursing diagnoses, the test taker first must make sure the diagnosis is correctly stated, and then make sure the diagnosis addresses the client problem pre- sented in the question. After safety is prioritized, the test taker must choose the diagnosis that, if resolved, would solve other client problems.

40. Which is the priority diagnosis for a client experiencing cocaine withdrawal? 1. Powerlessness. 2. Risk for injury. 3. Ineffective health maintenance. 4. Ineffective coping.

✅. 1.When a client withdraws from cocaine, the withdrawal symptoms are more psychological than physical. The intensely pleasurable effects of the drug create the potential for extraordinary psychological dependency, leading to powerlessness over the addiction. Powerlessness is the perception that one's own action would not significantly affect an outcome. This client's priority diagnosis is powerlessness. 2. Cocaine is a central nervous system stimulant, not a depressant, so there is no rebound of the nervous system during withdrawal and less chance of physical injury. 3. Ineffective health maintenance is the inability to identify, manage, or seek out help to maintain health. This is an appropriate nursing diagnosis for many clients diagnosed with substance abuse, not withdrawal. With these clients, all activities of life are focused on obtaining and using the substance of abuse, rather than maintaining health. 4. Ineffective coping is the inability to form a valid appraisal of stressors, inadequate choices of practiced responses, or inability to use available resources. This is an appropriate nursing diagnosis for many clients diagnosed with substance abuse, not withdrawal. These clients use substances to cope, rather than adaptive behaviors or problem solving. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must recognize the effects of cocaine withdrawal. This knowledge helps eliminate answer "2." Answers "3" and "4" can be eliminated because they relate to cocaine abuse, rather than withdrawal.

41. Which is the priority nursing diagnosis for a client experiencing cocaine intoxication? 1. Risk for altered cardiac perfusion. 2. Chronic low self-esteem. 3. Ineffective denial. 4. Dysfunctional grieving.

✅1. Central nervous system stimulants, such as cocaine, can induce increased systolic and diastolic blood pressure, increased heart rate, and cardiac arrhythmias. Cocaine intoxication also typically pro- duces an increase in myocardial demand for oxygen. These effects on the heart put a client experiencing cocaine intoxication at risk for altered cardiac perfusion. 2. Chronic low self-esteem is long-standing neg- ative self-evaluation and feelings about self or self-capabilities. This may be an appropriate diagnosis for a client experiencing cocaine abuse, not intoxication. Of the diagnoses pre- sented, it would not take priority. 3. Ineffective denial is the conscious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety or fear, leading to the detriment of health. This may be an appropriate diagnosis for a client experiencing cocaine abuse, not intoxication. Of the diagnoses presented, it would not take priority. 4. Dysfunctional grieving is the extended, unsuccessful use of intellectual and emotional responses by which individuals attempt to work through the process of modifying self- concept based on the perception of loss. Loss typically accompanies substance abuse, but there is no indication of behaviors that support this nursing diagnosis in the question. TEST-TAKING HINT: The test taker always must prioritize client safety. Only answer "1" could cause the client to be physically injured.

2. The nurse is working with a 45-year-old client who has abused alcohol since age 20. Related to this client's stage of psychosocial development, what developmental data would the nurse expect to assess? 1. The client may have trouble establishing intimate relationships. 2. The client may have trouble trusting others. 3. The client may review life, have serious regrets, and experience despair. 4. The client may feel a sense of inferiority or inadequacy.

✅1. Clients experiencing chronic substance dependence often arrest in developmental progression at the age when the abuse began. In this situation, the client began substance abuse at age 20. According to Erikson's psychosocial theory, the client's developmental conflict at this age would have been intimacy versus isolation. The major developmental task at this age is to form an intense, lasting relationship or a commitment to another person, cause, institution, or creative effort. Because of developmental arrest, this client may have trouble establishing intimate relationships. 2. According to Erikson's psychosocial theory, trust is established in the infancy (birth to 1 year) stage of development. If this client's psychosocial development were arrested at age 20, the establishment of trust would not be affected directly by the substance abuse. 3. According to Erikson's psychosocial theory, despair is the negative outcome of the old-age (65 years to death) stage of development. If this client's psychosocial development were arrested at age 20, despair would not as yet have been established because the client had not reached this age. 4. According to Erikson's psychosocial theory, feeling a sense of inferiority or inadequacy is the negative outcome of the school-age (6 to 12 years) stage of development. If this client's psychosocial development were arrested at age 20, the establishment of identity would not be affected directly by the substance abuse. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must understand and differ- entiate the developmental tasks at various stages of psychosocial development. Understanding that psychosocial development arrests because of sub- stance abuse allows the test taker to choose the correct stage based on the age at which the sub- stance abuse began.

55. What classification of drugs shares similar features with alcohol overdose and alcohol withdrawal? 1. Anxiolytics. 2. Amphetamines. 3. Cocaine. 4. Phencyclidine (PCP).

✅1.Alcohol is a central nervous system (CNS) depressant. Overdose symptoms are relat- ed to this depression, and withdrawal symptoms are related to a rebound of the CNS. Because anxiolytics (antianxiety medications such as barbiturates) also depress the CNS, they share similar features of alcohol overdose and withdrawal. 2. Amphetamines are CNS stimulants. Because they stimulate the CNS, they have an oppo- site effect from alcohol. There are few physi- cal withdrawal effects from the cessation of amphetamines. Withdrawal is psychological, not physical, in nature, including depression, anxiety, fatigue, and cravings. 3. Cocaine is a CNS stimulant. Because it stimulates the CNS, it has an opposite effect from alcohol. There are few physical withdrawal effects from the cessation of cocaine. Withdrawal is psychological, not physical, in nature, including depression, anxiety, fatigue, cravings, and paranoid thinking. 4. PCP is a hallucinogen. The effects produced by hallucinogens are highly unpredictable, in contrast to the effects of alcohol. During the use of PCP, the client can experience a panic reaction or "bad trip." This type of reaction may occur when a client withdraws from alcohol. There is no withdrawal from PCP. TEST-TAKING HINT: To determine the correct answer, the test taker must be able to distinguish the similarities of the signs and symptoms of alcohol overdose and withdrawal as they corre- late with the signs and symptoms of overdose and withdrawal from anxiolytic medications.

12. The emergency medical service brings an intoxicated client to the emergency depart- ment, after the client has been hit by a car while walking on the side of the road. The client states, "How did I get here? Who brought me to the hospital?" Which is the client most likely experiencing? 1. A blackout. 2. Denial. 3. Minimization. 4. Alcohol psychosis.

✅1.Blackouts are brief periods of amnesia that occur during or immediately after a period of drinking. Because this client cannot remember recent events and was intoxicated on admission, the client is likely experiencing a blackout. 2. Denial is the refusal to acknowledge the existence of a real situation or the feelings associated with it or both. Denial is a common defense mechanism used by clients diagnosed with alcoholism to enable them to ignore the consequences of alcohol abuse or dependence. Denial behaviors are not described in the question. 3. A client minimizes when amounts of drinking or the effect drinking has had on the client's life is depreciated and discounted. This defensive behavior usually occurs in the early alcoholic phase of drinking pattern progression. Minimization defenses are not described in the question. 4. Alcohol psychosis is a loss of contact with reality that results from acute or chronic alcohol use. This psychosis can be experienced during alcohol withdrawal syndrome. The symptoms of alcohol psychosis are not described in the question. TEST-TAKING HINT: To answer this question cor- rectly, the test taker should look for client symptoms in the question that indicate what the client is experiencing, and evaluate only the symptoms presented.

18. The following clients are waiting to be seen in the emergency department. Which client should the nurse assess first? 1. A cocaine abuser with chest pain. 2. An intoxicated client with a long history of alcoholism. 3. A client who recently experienced a "bad trip" from LSD. 4. A woman who thinks she has been given flunitrazepam (Rohypnol).

✅1.Cocaine intoxication typically produces an increase in myocardial demand for oxygen and an increase in heart rate. Severe vaso- constriction may occur and can result in myocardial infarction, ventricular fibrilla- tion, and sudden death. Because the client in the question is presenting with chest pain and has a history of cocaine abuse, the nurse should prioritize the assessment of this client. 2. A client would need immediate assessment if experiencing alcohol withdrawal, not intoxica- tion. This client would be at risk only if the intoxication was severe with extreme central nervous system depression. Because alcohol withdrawal begins within 4 to 12 hours of ces- sation or reduction in heavy and prolonged alcohol use, the nurse has time to assess this client for alcohol withdrawal. Of the clients described, this client would not take priority. 3. There is no physical withdrawal from hallu- cinogens such as lysergic acid diethylamide (LSD). A client experiencing a "bad trip" should be monitored closely to prevent self- injury as a result of extreme hyperactivity, hallucinations, and psychosis. Overdose symptoms also can include seizures. Because the client described is not currently experi- encing LSD overdose symptoms, this client would not take priority. 4. Flunitrazepam (Rohypnol) is a date rape drug. The effects of this drug include hypotension, confusion, visual disturbances, urinary retention, and aggressive behavior. It is important to assess for these symptoms and any signs of sexual assault. Psychological sup- port also is necessary. None of the signs and symptoms in the question is life-threatening, and so of the clients described, this client would not take priority. TEST-TAKING HINT: It is difficult to choose a pri- ority assessment when presented with clients in the emergency department. The test taker should look for signs and symptoms of condi- tions that can cause severe harm or death and for the timeframe of the presenting problem to determine if it is current and emerging, or if the nurse has some time to defer assessment.

26. A client brought to the emergency department is observed to be sweating, has dilated pupils, and complains of muscle aches and abdominal cramping. A toxicology screen is ordered. The nurse would suspect these symptoms are indicative of withdrawal from which substance? 1. Heroin. 2. Methamphetamine. 3. Flunitrazepam (Rohypnol). 4. Alcohol.

✅1.Heroin is an opioid derivative. Symptoms of heroin withdrawal include dilated pupils, muscle aches, diarrhea, and nausea and vomiting. Other symptoms are rhinorrhea, sweating, piloerection, yawning, fever, and insomnia. 2. Methamphetamine is a central nervous system stimulant. Symptoms of methamphetamine withdrawal include anxiety, depressed mood, irritability, cravings, fatigue, insomnia or hypersomnia, psychomotor agitation, and paranoid and suicidal ideations. The symptoms described in the question do not reflect withdrawal from methamphetamines. 3. Flunitrazepam (Rohypnol) is an antianxiety medication also known as a "date rape" drug. Symptoms of anxiolytic withdrawal include nausea and vomiting, malaise, weakness, tachycardia, sweating, anxiety, irritability, orthostatic hypotension, tremor, insomnia, and seizures. The symptoms described in the question do not reflect withdrawal from flunitrazepam (Rohypnol). 4. Alcohol is a central nervous system depressant. Symptoms of withdrawal include tremors, nausea and vomiting, malaise, weakness, tachycardia, sweating, elevated blood pressure, anxiety, depressed mood, irritability, hallucinations, headache, insomnia, and seizures. The symptoms described in the question do not reflect withdrawal from alcohol TEST-TAKING HINT: The test taker must distin- guish between the withdrawal symptoms of heroin, methamphetamine, flunitrazepam (Rohypnol), and alcohol to recognize the specific withdrawal symptoms described in the question.

13. What situation places an individual at highest risk for mood and behavioral changes related to alcohol consumption? 1. A 180-lb college student drinking four beers in a 1-hour period. 2. A 160-lb woman drinking one glass of red wine with a spaghetti dinner at a local restaurant. 3. A 250-lb man drinking four beers with hot dogs during a football game. 4. A 110-lb woman drinking a margarita with a combo platter at a Mexican restaurant.

✅1.The body burns alcohol at about 0.5 ounce per hour, so behavioral changes would not be expected in an individual who slowly consumes only one averagesized drink per hour. By consuming four drinks in a 1-hour period, however, this individual is likely to experience behavioral and mood changes. 2. Because it usually takes at least 1 hour to eat out at a restaurant, the client would be able to metabolize the wine at a pace that avoids behavioral and mood changes. Because the wine is consumed with food, the effect of the alcohol would be diminished further. 3. The timeframe of consumption, the man's body size, and the presence of food in the stomach all would contribute to a diminished alcohol effect on the body and not put this individual at risk for behavioral and mood changes. 4. Because it usually takes at least 1 hour to eat out at a restaurant, the client would be able to metabolize the alcoholic margarita at a pace that avoids behavioral and mood changes. Because the margarita is consumed with food, the effect of the alcohol would be diminished further. TEST-TAKING HINT: To answer this question, it is important for the test taker to know that an indi- vidual's size, whether the stomach is full, and how fast the individual drinks all are factors that influ- ence the effects of alcohol on behavior and mood.

34. What substance stimulates the central nervous system? 1. Vodka. 2. "Crack." 3. Lorazepam (Ativan). 4. Triazolam (Halcion).

"Crack" is a cocaine alkaloid that is extracted from its powdered hydrochloride salt by mixing it with sodium bicarbonate and allowing it to dry into small "rocks." 1. Vodka is a distilled alcohol. Alcohol is a central nervous system depressant, not stimulant. ✅2. "Crack" cocaine is classified as a stimulant. It is the most potent stimulant derived from natural origin. Cocaine is extracted from the leaves of the coca plant. 3. Lorazepam (Ativan) is a benzodiazepine. This classification of drug depresses, rather than stimulates, the central nervous system, and is often used to treat anxiety disorders. 4. Triazolam (Halcion) is a nonbarbiturate hypnotic, not a stimulant, that is used to treat sleep disorders. TEST-TAKING HINT: The test taker must under- stand the term "crack" to answer this question correctly. Crack is a cocaine alkaloid and is a stimulant.

59. The nurse is planning a teaching session for a client who has recently been prescribed disulfiram (Antabuse) as deterrent therapy for alcoholism. What statement indicates that the client has accurate knowledge of this subject matter? 1. "Over-the-counter cough and cold medication should not affect me while I am taking the Antabuse." 2. "I'll have to stop using my alcohol-based aftershave while I am taking the Antabuse." 3. "Antabuse should decrease my cravings for alcohol and make my recovery process easier." 4. "Antabuse is used as a substitute for alcohol to help avoid withdrawal symptoms."

Disulfiram (Antabuse) is a drug that can be administered to individuals who abuse alcohol as a deterrent to drinking. Ingestion of alcohol when disulfiram is in the body results in a syn- drome of symptoms that can produce discom- fort. Clients must be able to understand the need to avoid all alcohol and any food or over- the-counter medication that contains alcohol. 1. Over-the-counter cough and cold medica- tions often contain alcohol. This alcohol would affect a client who is taking disulfiram (Antabuse). ✅2. Alcohol can be absorbed through the skin. Alcohol-based aftershaves should be avoided when taking disulfiram (Antabuse). This client's statement indicates that the client has accurate knowledge related to this important information. 3. Disulfiram (Antabuse) is used as deterrent therapy and does not decrease alcohol cravings. Acamprosate calcium (Campral) is a drug that is used for maintenance of alcohol abstinence by decreasing cravings. 4. Disulfiram (Antabuse) is used as deterrent therapy, not substitution therapy. Benzodiazepines are the most widely used group of drugs for substitution therapy in alcohol withdrawal TEST-TAKING HINT: The test taker must under- stand the purpose of the use of disulfiram (Antabuse) and its potential side effects to recog- nize the client's statement that contains correct information regarding this medication.

21. What percentage of a single dose of alcohol is absorbed immediately into the blood- stream from which organ of the body? 1. 20% is absorbed through the stomach wall. 2. 30% is absorbed through the small intestines. 3. 40% is absorbed through the large intestines. 4. 50% is absorbed through the liver.

In contrast to foods, alcohol does not need to be digested. ✅1. 20% of a single dose of alcohol is absorbed directly and immediately into the bloodstream through the stomach wall. 2. 80% is processed only slightly more slowly through the upper intestinal tract and into the bloodstream. 3. 0% of alcohol is absorbed through the large intestines. 4. 0% of alcohol is absorbed through the liver. The liver filters alcohol from the bloodstream TEST-TAKING HINT: The keyword "immediately" determines the correct answer to this question. Immediate absorption of alcohol occurs only in the stomach.

29. A client with a long history of alcoholism presents in the emergency department with a sudden onset of muscle pain, swelling, and weakness, and reddish-tinged urine. What lab value would the nurse evaluate as evidence of this client's disorder? 1. Increase in CPK. 2. Increase in LDL. 3. Decrease in FBS. 4. Decrease in AST.

✅ 1. An increase in creatine phosphokinase (CPK), a muscle enzyme that is released when muscle tissue is damaged, occurs with alcoholic myopathy. Clients with acute alcoholic myopathy present with a sudden onset of muscle pain, swelling, and weakness. Reddish-tinged urine is caused by myoglobin, a breakdown product of muscle, excreted in the urine. 2. Low-density lipoproteins (LDLs) are not increased when a client is experiencing alcoholic myopathy. The enzyme lactate dehydrogenase (LDH) does increase. 3. There is no decrease in fasting blood sugar (FBS) when a client is experiencing alcoholic myopathy. 4. There is no decrease in aspartate aminotransferase (AST) when a client is experiencing alcoholic myopathy. Because AST is a liver function test, it may be elevated if liver damage has occurred because of a long history of alcohol abuse TEST-TAKING HINT: To answer this question cor- rectly, the test taker must know the signs and symptoms of alcoholic myopathy and understand what lab values reflect this diagnosis.

51. A client diagnosed with alcoholism is admitted to a substance abuse unit complaining of decreased exercise tolerance, lower extremity edema, arrhythmias, and dyspnea. Which nursing intervention would be appropriate for this client? 1. Providing thiamine-rich foods. 2. Administering digoxin (Lanoxin) and furosemide (Lasix). 3. Reorienting the client to person, place, and time. 4. Encouraging high-sodium foods.

. 1. The symptoms presented in the question are not symptoms that reflect a thiamine deficiency. Peripheral neuropathy, alcoholic myopathy, and Wernicke-Korsakoff syndrome all are caused by thiamine deficiencies. The symptoms presented are not indicative of these disorders. ✅2. The effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition. The clinical find- ings of alcoholic cardiomyopathy express themselves as symptoms of congestive heart failure. Besides total abstinence from alcohol, treatment includes digitalis, sodium restriction, and diuretics. 3. No cognitive alterations are presented in the question. Reorienting the client to person, place, and time would not address the physical problems presented. 4. The symptoms presented indicate that the client is experiencing alcoholic cardiomyopathy. Treatment should include sodium TEST-TAKING HINT: To answer this question correctly, the test taker must relate the client's history of alcoholism to the physical symptoms presented. When the client's cardiomyopathy has been identified, the choice of intervention should be clear.

57. A client with a long history of heroin abuse is showing signs of cognitive deficits. What drug would the nurse recognize as appropriate in assisting with this client's recovery? 1. Acamprosate calcium (Campral). 2. Buprenorphine/naloxone (Suboxone). 3. Disulfiram (Antabuse). 4. Haloperidol (Haldol).

1. Acamprosate calcium (Campral) is an amino acid derivative that is helpful in alcohol, not heroin, dependence. ✅2.Buprenorphine/naloxone (Suboxone) is approved by the Food and Drug Administration for opioid addiction. 3. Disulfiram (Antabuse) is a drug that can be administered to individuals who abuse alcohol, not heroin, as a deterrent to drinking. 4. Haloperidol (Haldol) is an antipsychotic medication that is not used for heroin recovery TEST-TAKING HINT: The test taker needs to understand the use of psychopharmacology relat- ed to abuse and withdrawal from various sub- stances to answer this question correctly.

30. A client has been diagnosed with Wernicke-Korsakoff syndrome. Which is an example of this client's use of confabulation? 1. The client has difficulty keeping thoughts focused and on topic. 2. The client clearly discussed a field trip, when in reality no field trip occurred. 3. The client jumps from one topic to another. 4. The client lies about anxiety level rating to receive more anxiolytics.

1. A client diagnosed with Wernicke-Korsakoff syndrome may have difficulty keeping thoughts focused, but this is not an example of confabulation. ✅2. Confabulation is the filling in of a memory gap with detailed fantasy believed by the teller. The purpose is to maintain self-esteem. Clients diagnosed with Wernicke- Korsakoff syndrome use confabulation to fill in missing recent memories. 3. When a client jumps from one topic to anoth- er in rapid succession, the client is experienc- ing the thought process of flight of ideas. This is not a description of confabulation. 4. A client who confabulates actually believes the story presented. Confabulation is an unconscious defense mechanism used to protect the client's self-esteem. This is different from a client who consciously lies to manipu- late for self-gratification. TEST-TAKING HINT: The test taker must under- stand the concept of unconscious confabulation and differentiate it from flight of ideas ("1"), tan- gential thinking ("3"), and conscious lying ("4").

19. A client diagnosed with alcohol dependency states that his wife complains about his alcoholism, but continues to stock his bar with large quantities of bourbon. The nurse suspects codependency. Which characteristic would the nurse expect the wife to exhib- it that would be indicative of this problem? 1. The wife has a long history of egocentric tendencies. 2. The wife is a "people pleaser" and would do almost anything to gain approval. 3. The wife does not feel responsible for making her husband happy. 4. The wife has an accurate understanding regarding her own identity.

1. A codependent person would have a long history of focusing thoughts and behaviors on other people rather than self. ✅2.A codependent person tends to be a "people pleaser" and would do almost anything to gain approval from others. 3. In order for a codependent person to feel good, the partner must be happy and behave in appropriate ways. If the partner is not happy, the codependent person feels responsible for making him or her happy. 4. A codependent person is confused about his or her own identity. In a relationship, a codependent person derives self-worth from the partner, whose feelings and behaviors determine how the codependent person should feel and behave. TEST-TAKING HINT: To answer this question correctly, the test taker needs to recognize the characteristics of an unhealthy dependence on another person.

58. A client receives lorazepam (Ativan) because of a high Clinical Institute Withdrawal Assessment (CIWA) score. What is the rationale for this pharmacologic intervention? 1. Lorazepam (Ativan) is a medication that decreases cravings in clients who are with drawing from alcohol dependence. 2. Lorazepam (Ativan) is a deterrent therapy to motivate clients to avoid alcohol. 3. Lorazepam (Ativan) is substitution therapy to decrease the intensity of withdrawal symptoms. 4. Lorazepam (Ativan) is a central nervous system stimulant that decreases the CIWA score.

Lorazepam (Ativan) is a central nervous system depressant used in alcohol detoxification. 1. Lorazepam (Ativan) does not decrease craving associated with alcohol dependency 2. Disulfiram (Antabuse), not lorazepam (Ativan), is a deterrent therapy to motivate clients to avoid alcohol. ✅3. Lorazepam (Ativan) is substitution therapy to decrease the intensity of withdrawal symptoms. The dosage depends on the severity of symptoms experienced during withdrawal, and this is objectively measured by the use of the Clinical Institute Withdrawal Assessment (CIWA) score. 4. Lorazepam (Ativan) is a central nervous system depressant, not stimulant, that works to decrease the client's withdrawal symptoms and lower the CIWA score. TEST-TAKING HINT: The test taker must under- stand the action of the drug lorazepam (Ativan) to recognize its use in substitution therapy.

49. A client is admitted for benzodiazepine dependence detox. This is the client's fourth detox, and the client's third detox was considered complicated. What would determine the nurse's priority intervention at this time? 1. The nurse must use confrontation because the client will use defense mechanisms such as denial, projection, and displacement to protect ego strength. 2. The nurse must provide empathetic support because the client will have little family support as a result of behaviors influenced by substance abuse. 3. The nurse must present the consequences of the client's actions because the client will have little motivation for change. 4. The nurse should monitor the client closely and initiate seizure precautions because the client will be at high risk for seizures.

During central nervous system (CNS) depres- sant withdrawal, the CNS rebounds, potentially causing life-threatening complications such as seizures. Repeated episodes of withdrawal seem to "kindle" even more serious withdrawal episodes, including the production of withdrawal seizures that can result in brain damage. A complicated withdrawal is a with- drawal in which complications such as seizures have occurred. 1. The nurse's priority intervention is not the use of confrontation to deal with the defense mechanisms of denial, projection, and displacement. Because of this client's high risk for complicated withdrawal, client safety takes priority. 2. The nurse's priority intervention is not providing empathetic support. Because of this client's high risk for complicated withdrawal, client safety takes priority. 3. The nurse's priority intervention is not presenting the consequences of the client's actions. Because of this client's high risk for complicated withdrawal, client safety takes priority. ✅4. Because of this client's high risk for complicated withdrawal, the nurse should monitor the client closely and initiate seizure precautions. Client safety takes priority. TEST-TAKING HINT: The test taker first must rec- ognize the situation presented in the question that puts the client at high risk for complications from benzodiazepine withdrawal. After this risk is determined, safety interventions must be prioritized.

3. Using the principles of biological theory, what contributing factor puts a client at risk for alcoholism? 1. The client is a child of an alcoholic parent. 2. The client is fixated in the oral phase. 3. The client is highly self-critical and has unconscious anxiety. 4. The client is unable to relax or defer gratification.

Numerous factors have been implicated in the predisposition to substance abuse. At present, there is not a single theory that can adequately explain the etiology of this problem. ✅1. A hereditary factor is involved in the development of substance use disorders, especially alcoholism. Children of alcoholics are three times more likely than other children to become alcoholics. Genetic theory falls under the category of biological theory. 2. The psychodynamic, not biological, theory of etiology of substance abuse disorders focuses on a punitive superego and fixation at the oral stage of psychosexual development. 3. Individuals with punitive superegos turn to alcohol to diminish unconscious anxiety. This is characteristic of psychoanalytic, not biological, theory. 4. Theories have associated addictive behaviors with certain personality traits. Clients who have an inability to relax or to defer gratifica- tion are more likely to abuse substances. This is from a developmental, not biological theory perspective TEST-TAKING HINT: The question requires the test taker to distinguish among various theo- ries of etiology of substance abuse disorders.Understanding the principles of biological theory assists the test taker to choose the correct answer.

14. Which of the following are parts of the CAGE questionnaire screening tool? Select all that apply. 1. Have you ever felt you should cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt guilty about your drinking? 4. Have you ever had a drink in the morning to steady your nerves? 5. Have you ever felt isolated, like you were in a cage?

The CAGE questionnaire screening tool is an assessment tool used to determine if an individ- ual abuses substances. ✅1. "Cut down" is the "C" of the CAGE assessment tool. ✅2. "Annoyed" is the "A" of the CAGE assessment tool. ✅3. "Guilty" is the "G" of the CAGE assess- ment tool. ✅4. "Eye opener," or having a drink in the morning as described in the question, is the "E," of the CAGE assessment tool. 5. Although clients experiencing alcoholism tend to isolate themselves from others, this is not a question contained in the CAGE assessment tool. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must know that "CAGE" is a mnemonic in which each letter represents a ques- tion in the CAGE assessment tool. This mnemonic assists the practitioner in remembering the categories of assessment addressed by this tool.

48. Ineffective denial is the nursing diagnosis that is appropriate at this time for a client who has relapsed into alcoholism. What is the priority nursing intervention to address this problem? 1. Help the client analyze the effects of substance abuse on life situations. 2. Set up an appointment for follow-up, and provide community resources. 3. Provide a stimulus-free environment. 4. Monitor vital signs.

✅1. The first step in decreasing the use of denial is for clients to see the relationship between substance use and personal problems. The nurse can assist with this by helping the client analyze the effects of substance abuse on life situations. 2. Setting up follow-up appointments and providing community resources are effective nursing interventions to help prevent relapse, but they do not directly address the nursing diagnosis of ineffective denial. 3. Providing a stimulus-free environment is a nursing intervention related to prevention of injury during alcohol withdrawal. This intervention does not directly address the nursing diagnosis of ineffective denial. 4. It is critical to monitor vital signs when a client is experiencing alcohol withdrawal because of the life-threatening nature of withdrawal symptoms. Monitoring vital signs does not address the client problem of ineffective denial. TEST-TAKING HINT: The test taker must note the nursing diagnosis assigned to the client in the question to determine the appropriate nursing intervention. Other nursing interventions may apply to clients with specific medical conditions, but the correct answer choice must be based on the nursing diagnosis presented in the question.

28. A newly admitted client with a long history of alcoholism complains of burning and tin- gling sensations of the feet. The nurse would recognize these symptoms as indicative of which condition? 1. Peripheral neuropathy. 2. Alcoholic myopathy. 3. Wernicke's encephalopathy. 4. Korsakoff's psychosis.

✅1.Peripheral neuropathy, characterized by peripheral nerve damage, results in pain, burning, tingling, or prickly sensations of the extremities. Researchers believe it is the direct result of deficiencies in the B vitamins, particularly thiamine. 2. Clients with acute alcoholic myopathy present with a sudden onset of muscle pain, swelling, and weakness; a reddish tinge in the urine caused by myoglobin, a breakdown product of muscle that is excreted in the urine; and a rapid increase in muscle enzymes in the blood. The symptoms described in the question do not reflect acute alcoholic myopathy. 3. Wernicke's encephalopathy is the most serious form of thiamine deficiency. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor. 4. Korsakoff's psychosis is identified by symptoms of confusion, loss of recent memory, and confabulation. It also is believed to be caused by a thiamine deficiency. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to match the symp- toms described with the disorders presented.

20. Which of the following are effective ways to identify a substance-impaired nurse? Select all that apply. 1. The nurse may frequently administer medications to other nurses' clients. 2. High absenteeism if the substance source is outside of work area. 3. Denial of substance abuse problems. 4. A high incidence of incorrect narcotic counts. 5. Poor concentration and difficulty in meeting deadlines.

✅All are correct Substance abuse and dependency become more serious problems when the impaired individual is responsible for the lives of others on a daily basis. All of the following are characteristic of an impaired nurse. 1. An impaired nurse may look for the oppor- tunity to administer medications to other nurses' clients, and there may be client complaints of inadequate pain control. 2. An impaired nurse has high absenteeism if the substance source is outside the work area. Conversely, the nurse may rarely miss work if the substance source is with- in the work area. 3. It is easy to overlook a problem when dealing with impaired nurses. Denial, on the part of the impaired nurse and nurse colleagues, is the refusal to acknowledge the existence of the situation or the feel- ings associated with it. 4. There may be an increase in "wasting" of drugs, higher incidences of incorrect narcotic counts, and a higher record of signing out drugs than for other nurses. 5. Poor concentration, difficulty in meeting deadlines, inappropriate responses, and poor memory and recall are usually appar- ent late in the disease process. TEST-TAKING HINT: To answer this question cor- rectly, it is important for the test taker to recog- nize and identify the characteristics of impair- ment that may occur in the workplace.