Chapter 31

The nurse is teaching a client about addiction. Which client statement indicates the education has been effective?

"A tolerance is built up over time, so more is needed to get the same effect."

Disulfiram should not be administered until a client has abstained from alcohol for at least how long?

12 hours

A nurse is caring for a client who uses phencyclidine (PCP). PCP is classified as which type of substance?

Hallucinogen

When discussing methadone treatment with a client, the nurse should include what?

It decreases the severity of heroin withdrawal symptoms.

Which characteristic of the 12-step program distinguishes it from other programs?

It is a self-help group that focuses on total abstinence.

Which medication is used to prevent Wernicke-Korsakoff syndrome?

Thiamine (Vitamin B1)

The nurse is preparing to discharge a client recovering from an addiction to an opioid. Which statement indicates to the nurse that teaching was effective?

"I plan to attend the group meetings."

The nurse is counseling a client that has maintained sobriety for 90 days. The client states, "I still have cravings and don't know how I am going to stay sober for the rest of my life. What if I can't do it in the long run?" Which is the most therapeutic response by the nurse?

"Let's look at this in the short term and determine what you can do to stay sober today."

The nurse is interviewing family members of a client being treated for substance use disorder. Which statement by a family member would alert the nurse to the possibility of codependency?

"My sibling would not drink as much if their spouse was more understanding."

A client is admitted for the third time for a substance use disorder. Which statement indicates the nurse is approaching the client with an open and objective attitude?

"Sometimes it takes a few times before relapses stop occurring."

A client has entered treatment for alcohol dependency at the client's spouse's insistence. The client's spouse has threatened to leave the marriage unless the client seeks treatment. The client admits that the client drinks every day, but that the drinking is well in control. The nurse recognizes the client's comments as denial. What is the best response by the nurse?

"What negative consequences have resulted from your drinking?"

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. The nurse recognizes these symptoms as typical of which of the following?

Alcohol Withdrawal syndrome

Supported by research results, the mental health nurse includes alcohol-related problem assessment questions when interviewing which of the following client groups?

All clients regardless of age and gender

The nurse is working in an intensive care unit and observes that some clients do not respond to injections of diazepam 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?

Call the manager and report the observations.

A client is brought to the emergency department by a friend who tells the staff that the friend thinks the client has overdosed on cocaine. Which finding(s) would help support this suspicion? Select all that apply.

Client reports chest pain Seizure activity occuring Heart rate of 138 beats per minute

A nurse is caring for a client with an acute substance intoxication. The client's pupils are dilated, and the nurse notes the client's blood pressure is 166/108 mm Hg. Which substance is the most likely cause of the client's symptoms?

Cocaine

A client is diagnosed with Korsakoff amnesic syndrome. Which of the following would the nurse most likely assess? Select all that apply.

Confabulation Attention deficit Vision impairment

As a component of the standard nursing admission assessment at the hospital, a nurse is using the CAGE tool. Which of the following questions will the nurse ask the c

Have you ever felt like you should cut down on your drinking?"

The nurse in an outpatient rehabilitation program is speaking with a group of clients who have recently recovered from alcohol abuse. Which issue should the nurse raise before the clients leave for the day?

Help them to identify appropriate diversional activities.

The nurse is talking with the spouse of a client admitted for substance use disorder and overdose. Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.

I am so scared about my spouse getting fired; I often call in sick so they won't." "If I don't give them money for the drugs, they will just steal it anyway." "My spouse had a terrible childhood and I would probably do the same things."

The nurse is interviewing a client with alcohol use disorder. Which client statement would alert the nurse that the client is not coping with their addiction?

I appreciate the help I'm getting and now I can stop drinking on my own."

The nurse is leading a family therapy group with a client addicted to alcohol. Which statement made by the spouse indicates the need for additional education regarding alcoholism as a family illness?

I have to call in sick for the client when the client is too hung over to go to work." One type of codependent behavior is called enabling, which is a behavior that seems helpful on the surface but actually perpetuates the substance use. Covering for the client when they are too hungover to work perpetuates addictive behaviors because it spares them from the natural consequences of the client's actions.

The charge nurse observes another nurse reporting for work looking unkempt and disheveled with uncoordinated movements and breath smelling of alcohol. Which is the priority action by the charge nurse?

Immediately call the supervisor to report the nurses' behavior.

The nurse is educating a client with alcoholism that has been in rehabilitation for two weeks to prepare for discharge. Which statement made by the client indicates that education was effective and the client is best prepared for discharge?

In order to give myself the best chance for sobriety, I will abstain from alcohol."

The nurse is caring for a client with opioid addiction who is on a methadone treatment plan. Which statement about methadone does the nurse understand is the reason it is used for opioid detoxification?

It has a long half-life. Explanation: Methadone is a medication that is used to treat opioid dependence. It works by binding to the same brain receptors as opioids, but it does not produce the same "high" as opioids. Methadone can help people who are trying to quit using opioids by reducing cravings and withdrawal symptoms. Methadone is used because of its long half-life, but it also leads to physiologic addiction and is a potent opioid. However, under daily monitoring and treatment, methadone can be a highly effective treatment for opioid addiction.

A client is experiencing severe alcohol withdrawal. Which would the nurse identify during the assessment that correlates with the withdrawal symptoms? Select all that apply

Marked diaphoresis Auditory hallucinations Gross uncontrollable tremors

Which of the following is used as a substitute for heroin in some maintenance programs?

Methadone

A client with a history of alcohol use disorder has presented to the emergency department with hallucinations and relays being followed by the police. Which action will the nurse take given this information?

Monitor for Korsakoff syndrome from long-term effects of alcohol use.

A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

Monitor respiratory function

A client is admitted for a drug overdose with a central nervous system (CNS) depressant. The priority nursing action when planning care for this client would be to ..

Monitor respiratory function.

A client is admitted for a drug overdose with a central nervous system (CNS) depressant. The priority nursing action when planning care for this client would be to ...

Monitor respiratory function. Explanation: CNS depressants depress respiratory functioning

A client is receiving treatment for opioid toxicity. Which drug reverses opioid toxicity?

Naloxone (Narcan)

The nurse is visiting the home of a client with a substance use disorder. Which observation indicates to the nurse that the client's behavior is being enabled?

Parent tells the client that attending an Alcoholics Anonymous meeting is not necessary.

The nurse suspects that another nurse is taking controlled substances from the narcotics drawer. Which action would the nurse take to address this issue?

Share the suspicion with the nurse manager.

A client is admitted to the emergency department after using MDMA (Ecstasy). The nurse identifies this drug as belonging to what class?

Stimulant Explanation: MDMA (3-4 methylenedioxymethamphetamine), or Ecstasy or Molly, is a stimulant and is known as a "designer drug" because it is used by teens and young adults as part of the nightclub, bar, and rave scenes. MDMA, similar in structure to methamphetamine, causes serotonin to be released from neurons in greater amounts than normal. Once released, this serotonin can excessively activate serotonin receptors.

Which factor would contraindicate the use of disulfiram in the treatment of a client who has an alcohol use disorder?

The client had six drinks a few hours ago.

The nurse is gathering data on a client who drinks vodka every day, gradually increasing over the past 2 to 3 years. The client maintains a job, home, and marriage. How will the nurse document the assessment data?

The client has developed a tolerance. Explanation: Tolerance is characterized by a need for more of a substance to achieve the same effects from it. Abuse describes maladaptive behaviors related to alcohol or other substances. Withdrawal is a set of symptoms that occur when a client is not ingesting a substance used regularly. Intoxication is the level of alcohol in the bloodstream, and/or demonstration of impaired behavior. This client does not display intoxication but rather tolerance to the alcohol. The client has not given any indication of other substance use.

The client was diagnosed with cocaine abuse at age 30. When the client was 23, the client was diagnosed with major depressive episode, and has continued to have depression off and on since then. Which statement would reflect this situation?

The client most likely has a dual diagnosis since she has both a substance dependence and depression.

The nurse is working with a client with alcohol use disorder that has difficult behaviors to manage. Which action by the nurse is a priority to effectively care for this client?

The nurse must recognize their own beliefs, backgrounds, and attitudes related to substance use disorder.

Wernick-Korsakoff syndrome is a neurologic condition that can result from heavy drinking. Which of the following medications is used to prevent Wernicke-Korsakoff syndrome?

Thiamine (Vitamin B1) Thiamine is used to prevent Wernicke-Korsakoff syndrome. Folic acid, vitamin B12, and lorazepam are not used for this disease process.

A nurse is conducting a class for a group of high school students about marijuana use and abuse. The nurse determines that the class needs further discussion when they state which of the following?

Users of marijuana always experience relaxation and euphoria.

Substamce misuse

Usin it for not intended it to be

A client is admitted to the emergency department for intoxication with alcohol. The client has an unsteady gait, myopathy, and neuropathy and cannot remember past or recent events. When treated with thiamine, the client's symptoms greatly improve. Which condition was the client likely experiencing?

Wernicke-Korsakoff syndrome

Which of the following substances is abused most often in the United States?

alcohol

The nurse is caring for a client with chronic alcohol use disorder that is experiencing an alteration in memory function. Which laboratory result will the nurse correlate with this assessment finding?

decreased thiamine level

The nurse is caring for a client with delirium tremens (DTs). Which development constitutes a medical emergency?

development of seizure activity Explanation: The development of seizure activity during alcohol-induced delirium tremens (DTs) is a life-threatening situation and must be considered a medical emergency. Atrial fibrillation on the monitor does not constitute a medical emergency but should be reported to the health care provider. Because chronic alcohol dependence can lead to organ failure such as cirrhosis, developing jaundice should be reported but is not likely. Irritability, anxiety, and delusions during DTs should be reported but are not considered a medical emergency. Urine that has a coffee appearance could indicate kidney failure as well and should be reported,

A client is brought to the emergency department by law enforcement after suspicion of driving under the influence. A blood alcohol level is drawn and is found to be 0.10 mg%. Which of the following would the nurse expect to assess?

difficulty coordinating movements

A nurse is performing an assessment for a client brought in by a family member, who tells the nurse they think the client has been using inhalants today. Which effect(s) does the nurse observe that indicates the client has likely used inhalants? Select all that apply.

euphoria aggressiveness dizziness Stumbling gait

A client is brought to the emergency department following a car accident. The client's blood alcohol level (BAL) is 0.10%. Which of the following would the client likely exhibit?

impaired coordination With a blood alcohol level (BAL) of 0.10%, the person would most likely demonstrate difficulty driving and coordinating movement. Giddiness would be noted with a BAL of 0.05%. Ataxia and emotional lability would be noted with a BAL of 0.20%.

A nursing student is aware that which accounts for more deaths, illnesses, and disabilities across the life span than any other preventable condition?

substance abuse disorders