Medical Surgical Nursing Lewis Chapter 10 - Substance Use Disorders, Mental Health Nursing: Substance Use & Addictive Disorders, LEWIS CH 10 Substance abuse

CASE STUDY - Cocaine Toxicity Patient Profile N.C. is a 34-year-old man who was admitted to the emergency department with chest pain, tachycardia, dizziness, nausea, and severe migraine-like headache. Subjective Data • He thinks he is having a heart attack. • Admits he was at a party earlier in the evening drinking alcohol, smoking pot, and snorting cocaine. • States he became irritable and restless. • States he has experienced an increased need for cocaine in the past few months. Objective Data • Appears extremely nervous and irritable • Appears pale and diaphoretic • Has tremors • BP 210/110, HR 100 bpm, RR 30 Discussion Questions Using a separate sheet of paper, answer the following questions: 1. What other information is needed to assess N.C.'s condition? 2. How should questions related to these areas be addressed?

1. Because there is a tendency among substance abusers to take a variety of drugs simultaneously or in a sequence to obtain specific effects, as shown by this patient's history, he should be assessed for his pattern of abuse. Regular alcohol use in addition to other drug use or the common use of cocaine in combination with heroin or phencyclidine hydrochloride could cause withdrawal symptoms and additional manifestations that would complicate his condition and direct his care. Information about all of the drugs he uses, including both over-the-counter (OTC) and prescription drugs, is necessary to avoid withdrawal syndromes, acute intoxication, overdose, or drug interactions that might be life threatening. 2. The nurse should be aware that common behaviors that are likely to influence history taking from this patient include manipulation, denial, avoidance, underreporting or minimizing substance abuse, giving inaccurate information, and inaccurate self-reporting. To obtain reliable information about his drug abuse patterns, the nurse should first explain that information about his drug use is essential in the monitoring for and prevention of serious effects of the drugs while he already is very ill. Providing a need for the information and explaining how the information will be used may facilitate more honest responses by the patient. The nurse should question him without judgment about his pattern of abuse with open-ended questions such as "How much or how often do you use alcohol?" or "Can you describe how you use cocaine with other drugs?"

CASE STUDY CONTINUED 3. What other clues should the nurse be alert for in assessing N.C.'s drug use? 4. What emergency conditions must be carefully monitored? 5. Priority Decision: What are the priority nursing interventions?

3. Physical effects of drug use that provide clues to drug abuse include collapsed and scarred veins used to inject drugs, nasal septum and mucosa damage, brown or black sputum production, and wound abscesses and cellulitis. 4. Continuous monitoring of this patient's vital signs, cardiac activity, level of consciousness, respiratory status, temperature, fluid and electrolyte balance, liver function, and renal function is necessary. Complications of cocaine toxicity that may occur and can be detected by monitoring include myocardial ischemia or infarction, heart failure, cardiopulmonary arrest, rhabdomyolysis with acute renal failure, stroke, respiratory distress or arrest, seizures, agitated delirium and hallucinations, electrolyte imbalances, and fever. In severe intoxication the patient may progress rapidly through stages of stimulation and depression, which may result in death. His use of cocaine with alcohol also increases his risk of liver injury and sudden death. 5. Assessment for neurologic, cardiovascular, and respiratory problems as described above is a critical nursing intervention in the patient with cocaine toxicity. In addition, the nurse should institute seizure precautions, provide airway management, keep open IV lines, administer medications aggressively as prescribed, and use cardiac lifesupport measures as indicated. Nursing interventions that are indicated for his anxiety, nervousness, and irritability include explaining procedures using short, simple, clear statements in a calm manner; providing a safe, secure environment; decreasing environmental stimuli; reinforcing reality orientation; and encouraging participation in relaxation exercises if possible.

CASE STUDY CONTINUED 6. What is the best way to approach N.C. to engage him in a treatment program? 7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

6. Engaging an individual who is addicted to cocaine in treatment is difficult because of the intense craving for the drug and a strong denial that cocaine is addicting or that the individual cannot control it. Motivational interviewing is indicated in even this initial encounter with this patient. The nurse should help him to increase his awareness of risks and problems related to his current behavior and create doubt about the use of substances. Asking him what he thinks could happen if the behavior continues, pointing out the physical symptoms he is experiencing, and offering factual information about the risks of substance abuse are indicated. Often the only motivation for a patient with a cocaine addiction to enter a treatment program is family threats, loss of job or professional license, legal action, or major health consequences. A treatment program is indicated to provide him with new skills and an ability to deal with his addictive behavior. 7. Nursing diagnoses: • Ineffective health maintenance • Risk-prone health behavior • Impaired memory • Ineffective denial • Ineffective coping Collaborative problems: Potential complications: cardiopulmonary arrest, seizures, sudden death, cerebrovascular accident, acute renal failure

Which pt behaviours should the nurse suspect as related to alcohol withdrawal? 1. Hyperalert state, jerky movements, easily startled 2. Tachycardia, diaphoresis, elevated BP 3. Peripheral vascular collapse, electrolyte imbalance 4. Paranoid delusions, fever, fluctuating levels of conciousness

ANS: 1 1. Patients who are exhibiting hyperalertness and jerky movements and who startle easily are most likely in a state of alcohol withdrawal, a condition that peaks in 24 to 48 hours after cessation or reduction of alcohol intake and then rapidly and dramatically disappears unless the withdrawal process progresses to alcohol withdrawal delirium. 2. Tachycardia, diaphoresis, and elevated blood pressure are associated with alcohol delirium and are considered a medical emergency and can result in death if not treated. 3. Peripheral vascular collapse and electrolyte imbalance are associated with alcohol delirium and are considered a medical emergency and can result in death if not treated. 4. Paranoid delusions, fever, and fluctuating levels of consciousness are associated with alcohol delirium and are considered a medical emergency and can result in death if not treated.

Nursing assessment of an alcohol-dependent patient 6 to 12 hours after the last drink would most likely reveal the presence of which of the following? 1. Tremors 2. Seizures 3. Blackouts 4. Hallucinations

ANS: 1 Tremors are an early sign of alcohol withdrawal. The presence of seizures is at high risk at 24-48 hours.

Which condition would the nurse be most concerned about when caring for a patient who abuses alcohol? 1. Cirrhosis of the liver 2. Suicidal potential 3. Wernicke's encephalopathy 4. Korsakoff syndrome

ANS: 2 1. Although the patient may develop or present with cirrhosis, the nurse must first plan care for prevention of self-harm. 2. Safety is always the priority when caring for patients. Ensuring safety includes completing a suicide risk assessment. 3. Wernicke's encephalopathy may develop, but the nurse must first plan care for prevention of self-harm. 4. Korsakoff syndrome is not the priority of care.

The nurse is caring for a patient with an addictive disorder who is currently drug-free. The pt is experiencing repeated occurrences of viid, frightening images and thought. Which term would the nurse use to document this finding? 1. Tolerance 2. Flashbacks 3. Withdrawal 4. Synergistic effect

ANS: 2 1. Tolerance occurs when a patient's physiological reaction to a drug decreases with repeated administration of the same dose. 2. Flashbacks occur in a drug-free state and involve visual distortions, time expansion, loss of ego boundaries, and intense emotions. Often, flashbacks are mild and perhaps pleasant, but at other times, individuals experience repeated recurrences of frightening images or thoughts. 3. Withdrawal causes physiological changes as blood and tissue concentrations of a drug decrease in individuals who have maintained heavy and prolonged use of a substance. 4. The term synergistic effect is used when drugs are taken together and the effect of either or both drugs is intensified.

A patient brought to the emergency department after phenylcyclohexyl piperidine (PCP) ingestion is both verbally and physically abusive, and the staff is having difficulty keeping him and themselves safe. Which of the following nursing interventions would be most therapeutic? 1. Taking him to the gym on the psychiatric unit 2. Obtaining an order for seclusion and close observation 3. Assigning a psychiatric technician to "talk him down" 4. Administering naltrexone as needed per hospital protocol

ANS: 2 Aggressive, violent behaviour is often seen with PCP ingestion. The patient will respond best to a safe, low-stimulus environment such as that provided by seclusion until the effects of the drug wear off. Talking down is never advised because of the patient's unpredictable violent potential. Naltrexone is an opiate antagonist.

Cocaine exerts which of the following effects on a patient? 1. Stimulation after 15 to 20 minutes 2. Stimulation and anesthetic effects 3. Immediate imbalance of emotions 4. Paranoia

ANS: 2 Cocaine exerts two main effects on the body: anesthetic and stimulant.

Which patient response to the question "Have you ever drunk more alcohol or used more drugs than you meant to?" should immediately cause the nurse to assess further? 1. "No, I have never used drugs or alcohol." 2. "I have drunk alcohol before but have ever never let myself get drunk." 3. "I figured you'd ask me about that." 4. "Yes, I did that once and will never do it again."

ANS: 3 1. No further assessment is immediately required. 2. Further assessment would be appropriate through the context of the general assessment; however, alcohol and drug use would not be the immediate priority. 3. Automatic responses such as "I figured you'd ask me about that" serve as red flags that further assessment must be done right away to provide clarification. 4. No further assessment is immediately required.

Which of the following is the most helpful message to transmit about relapse to the patient recovering from alcohol abuse? 1. Relapses are an indicator of treatment failure. 2. Relapses are caused by physiological changes. 3. Relapses result from lack of good situational support. 4. Relapses can be learning situations to prolong sobriety.

ANS: 3 Relapses and lapses can point out problems to be resolved and can result in renewed efforts for change.

Which of the drugs used by a polysubstance abuser is most likely to be responsible for withdrawal symptoms requiring both medical intervention and nursing support? 1. Opiates 2. Marijuana 3. Barbiturates 4. Hallucinogens

ANS: 3 Withdrawal from central nervous system depressants is complicated, requiring carefully titrated detoxification with a similar drug. Abrupt withdrawal can lead to death.

A patient has been using cocaine intranasally for 4 years. When the patient is brought to the hospital in an unconscious state, nursing measures should include which of the following? 1. Induction of vomiting 2. Administration of ammonium chloride 3. Monitoring of opiate withdrawal symptoms 4. Observation for hyperpyrexia and seizures

ANS: 4 Hyperpyrexia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose.

Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colourful d. Confrontational and challenging

ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."

At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as which of the following? a. Codependence b. Assertiveness c. Role reversal d. Homeostasis

ANS: A Codependence refers to participating in behaviours that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. See relationship to audience response question.

During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behaviour carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

ANS: A During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defence mechanism? a. Denial b. Projection c. Introjection d. Rationalization

ANS: A Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one's own personality.

Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

ANS: A Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

Select the most therapeutic manner for a nurse to work with a patient who is beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counselling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defences.

Which of the following symptoms would signal opioid withdrawal? a) Rhinorrhea, chills, fever, and muscle aches b) Illusions, disorientation, tachycardia, and tremors c) Fatigue, lethargy, sleepiness, and convulsions d) Synesthesia, depersonalization, and hallucinations

ANS: A Symptoms of opioid withdrawal resemble the "flu"; they include runny nose, tearing, diaphoresis, muscle aches, cramps, chills, and fever.

Select the priority outcome for a depressed patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will do which of the following? a. State, "I know I need long-term treatment." b. Use denial and rationalization in healthy ways. c. Identify constructive outlets for expression of anger. d. Develop a trusting relationship with one staff member.

ANS: A The correct option refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. The pharmacokinetics of the alcohol has changed.

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither delayed metabolism nor antagonistic effects account for this change.

What behaviours would the nurse expect to assess in a nontolerant drinker with a blood alcohol level of 0.20 mg%? Select all that apply. a. Ataxia b. Staggering c. Confusion d. Stupor e. Emotional liability

ANS: A, B, E The nurse would see staggering, ataxia, and emotional lability in a nontolerant drinker with a blood alcohol level (BAL) of 0.20 mg%. Confusion and stupor are seen with BALs of 0.30 mg% and higher.

The nurse can assist a patient to prevent substance abuse relapse by doing which of the following? Select all that apply. a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Advising isolating self from significant others until sobriety is established e. Informing the patient of physical changes to expect as the body adapts to functioning without substances

ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia (loss of full control of bodily movements) and slurred speech. The blood alcohol level is 0.50 mg%. Considering the relationship between the behaviour and blood alcohol level, which conclusion is most probable? a. The patient rarely drinks alcohol. b. The patient has a high tolerance to alcohol. c. The patient has been treated with disulfiram (Antabuse). d. The patient has ingested both alcohol and sedative drugs recently.

ANS: B A nontolerant drinker would be in coma with a blood alcohol level of 0.50 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behaviour and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. a. "Alcoholics Anonymous is a form of group therapy led by a psychiatrist." b. "Alcoholics Anonymous is a self-help group for which the goal is sobriety." c. "Alcoholics Anonymous is a group that learns about drinking from a group leader." d. "Alcoholics Anonymous is a network that advocates strong punishment for drunk drivers."

ANS: B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or that the patient is presently in need of restraint. Hydration will not resolve the problem.

A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

ANS: B Immediate medical attention, ongoing assessment and supervised treatment is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic

ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority. See relationship to audience response question.

A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe which of the following? a. A narcotic analgesic, such as hydromorphone (Dilaudid) b. A benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium) c. An antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril) d. A monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil)

ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory centre secondary to narcotic intoxication. Select the priority outcome. a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

ANS: B The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.

An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. Which of the following should the nurse suspect? a. A schizophrenic episode b. Hallucinogen ingestion c. Opium intoxication d. Cocaine overdose

ANS: B The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about "going crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviours. Phencyclidine (PCP) use commonly causes bizarre or violent behaviour, nystagmus, elevated vital signs, and repetitive jerking movements.

Which of the following symptoms of withdrawal from opioids should the nurse assess? a. Dilated pupils, tachycardia, elevated blood pressure, and elation b. Nausea, vomiting, diaphoresis, anxiety, and hyperreflexia c. Mood lability, incoordination, fever, and drowsiness d. Excessive eating, constipation, and headache

ANS: B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while working through a 12-step plan." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

ANS: B Using the 12 steps, often referred to as "working the steps," helps a person refrain from addictive behaviours while fostering individual change and growth. Peer support, accomplished by obtaining a sponsor prior to discharge, can increase the patient's likelihood of attendance at 12-step meetings. The other options are incorrect.

Which of the following would be part of the treatment plan for a person experiencing alcohol overdose? Select all that apply. a. Monitor vital signs every 5 minutes b. Monitor for respiratory depression c. Maintain hydration with IV fluids d. Administer antipsychotic medication e. Administer oxygen

ANS: B, C, E Correct aspects of the treatment plan for this patient would be to monitor for respiratory depression, maintain hydration with IV fluids, and administer oxygen. Vital signs are to be monitored; however every 5 minutes is too often—every 15 minutes is sufficient. There is no indication that the patient requires an antipsychotic medication.

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, and diaphoretic and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. a. The patient is attempting to obtain attention by manipulating staff. b. The patient may have sustained a head injury before admission. c. The patient has symptoms of alcohol-withdrawal delirium. d. The patient is having an acute psychosis.

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

What is the most significant predictor of treatment success, considering the ambivalence of most patients? a) Ongoing support from at least two family members. b) Employment of the patient. c) An empathic, hopeful, and consistently motivational approach. d) A regular schedule of appointments with a primary care provider.

ANS: C The most significant predictor of treatment success, considering the ambivalence of most of these patients, is an empathic, hopeful, and consistently motivational approach. This is the rationale behind motivational interviewing approaches.

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

ANS: C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

A young woman has been admitted to hospital for use of room deodorizers as inhalants. Which is a sign of intoxication from inhaling volatile nitrites such as room deodorizers? a. Flushing b. Hallucinations c. Slurred speech d. Enhancement of sexual pleasure

ANS: D A sign of intoxication from inhaling volatile nitrites such as room deodorizers is enhancement of sexual pleasure. Flushing, hallucinations, and slurred speech are signs of intoxication from inhaling organic solvents.

Benzodiazepines are useful for treating alcohol withdrawal because they do which of the following? a. Block cortisol secretion b. Increase dopamine release c. Decrease serotonin availability d. Exert a calming effect

ANS: D Benzodiazepines act by binding to α-aminobutyric acid-benzodiazepine receptor sites, producing a calming effect.

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviours consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

What is the ethical obligation of the nurse who sees a peer divert a narcotic, compared with the ethical obligation when the nurse observes a peer who is under the influence of alcohol? a) The nurse should immediately report the peer who is diverting narcotics and should defer reporting the alcohol-using nurse until a second incident takes place. b) Neither should be reported until the nurse has collected factual evidence. c) No report should be made until suspicions are confirmed by a second staff member. d) Supervisory staff should be informed as soon as possible in both cases.

ANS: D If indicators of impaired practice are observed, the observations need to be reported to the nurse manager. Intervention is the responsibility of the nurse manager and other nursing administrators. However, clear documentation (specific dates, times, events, consequences) by co-workers is crucial. The nurse manager's major concerns are with job performance and patient safety. Reporting an impaired colleague is not easy, even though it is our responsibility. To not "see" what is going on, nurses may deny or rationalize, thus enabling the impaired nurse to potentially endanger lives while becoming sicker and more isolated. Impairment can occur whether the nurse is under the influence of alcohol or a narcotic drug.

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Naloxone (Targin) b. Methadone (Metadol) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)

ANS: D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol-free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behaviour."

ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviours, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviours or are of no help.

A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

ANS: D The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defences against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

Which goal for treatment of alcoholism should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiologic stability.

ANS: D The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

ANS: D The patient's clouded sensorium, sensory perceptual distortions, and poor judgement predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care.

A patient is thin, tense, and jittery and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

ANS: D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behaviour. Barbiturates and heroin would result in symptoms of CNS depression.

A patient took a large quantity of phenylcyclohexyl piperidine. Priority nursing and medical measures include which of the following? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Management of heart rate e. Environmental safety

ANS: D, E Care of patients who have taken phenylcyclohexyl piperidine (PCP) is similar to the care of those who have used other stimulants. Tachycardia and chest pain are common when a patient has used PCP. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behaviour or paranoia (or both); therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

What is given when benzodiazapines are the cause of CNS depression?

Flumazanil

What is given when opiods are the cause of CNS depression?

Naloxone

List two major health problems commonly seen in the acute care setting related to the abuse of the following substances. Nicotine a. b. Alcohol a. b. Cocaine and amphetamines a. b. Opioids a. b. Cannabis a. b.

Nicotine a. Chronic obstructive pulmonary disease (COPD) b. Cancers: lung, mouth, larynx, esophagus, stomach, bladder, pancreas Others: coronary artery disease, peripheral artery disease, peptic ulcer disease, gastroesophageal reflux disease (GERD) (see Table 11-2) Alcohol a. Dementia b. Cirrhosis Others: peripheral neuropathy, increased risk for several cancers, anemia, coronary artery disease (CAD), hypertension, GERD (see Table 11-7) Cocaine and amphetamines a. Cardiac dysrhythmias b. Psychosis Others: nasal sores, myocardial infarction (MI), stroke (see Table 11-2) Opioids a. Gastric ulcer b. Glomerulonephritis Other: sexual dysfunction (see Table 11-2) Cannabis a. Bronchitis, chronic sinusitis b. Memory impairment Other: impaired immune system, reproductive dysfunction (see Table 11-2)

15) During the admission to the emergency Department a patient with chronic alcoholism is intoxicated and very disoriented and confused. Which drug will the nurse administer first? a) IV thiamine. b) IV benzodiazepines. c) IV haloperidol. d) IV naloxone in NS.

a) IV thiamine.

5) Which substance, when used by the patient with SUD, can cause euphoria, drowsiness, decreased respiratory rate and slurred speech? a) Opioids. b) alcohol. c) cannabis. d) depressants.

a) Opioids.

A patient who is a heavy caffeine user has been NPO all day in preparation for late afternoon in surgery. the nurse monitors the patient for the effects of caffeine withdrawal that may include a) headache. b) nervousness. c) Mild tremors. d) shortness of breath.

a) headache.

A patient with a history of alcohol use disorder is admitted to the hospital following an automobile accident. What is most important for the nurse to assess to plan care for the patient ? a) when the patient last had alcohol intake. b) how much alcohol has recently been used. c) what type of alcohol has recently been ingested. d) the patients current blood alcohol concentration

a) when the patient last had alcohol intake.

Match the following drugs used for treatment of cocaine toxicity with their specific uses (answers may be used more than once). ___a. Haloperidol (Haldol) ___b. IV lidocaine ___c. IV diazepam (Valium) ___d. Propranolol (Inderal) ___e. Bretylium (Bretylol) ___f. IV lorazepam (Ativan) ___g. Procainamide (Pronestyl) 1. Tachycardia 2. Hallucinations 3. Dysrhythmias 4. Seizures

a. 2; b. 3; c. 4; d. 1; e. 3; f. 4; g. 3

As health care professionals, nurses have a responsibility to help reduce the use of tobacco. List the recommended "five As" as brief clinical interventions. a. b. c. d. e.

a. Ask; b. Advise; c. Assess; d. Assist; e. Arrange

Priority Decision: During admission to the emergency department, a patient with chronic alcoholism is intoxicated and very disoriented and confused. Which drug will the nurse administer first? a. IV thiamine b. IV benzodiazepines c. IV haloperidol (Haldol) d. IV naloxone (Narcan) in normal saline

a. Because Wernicke's encephalopathy resulting from a thiamine deficiency is a possibility with chronic alcoholism, IV thiamine is often administered to intoxicated patients to prevent the development of Korsakoff's psychosis. Thiamine should be given before any glucose solutions are administered because glucose can precipitate Wernicke's encephalopathy. Benzodiazepines may be used for sedation and to minimize withdrawal symptoms but would not be given before thiamine, and haloperidol could be used if hallucinations occur.

A young woman is brought to the emergency department by police who found her lying on a downtown sidewalk. The initial nursing assessment finds that she is unresponsive and has a weak pulse of 112; shallow respirations of 8 breaths/minute; and cold, clammy skin. Identify the two medications that would most likely be given immediately to this patient and explain why they would be given. a. b.

a. Naloxone (Narcan) is given when opioids are the cause of central nervous system (CNS) depression. b. Flumazenil (Romazicon) is given when benzodiazepines are the cause of CNS depression.

Which substance, when abused, can cause euphoria, drowsiness, decreased respiratory rate, and slurred speech? a. Opioids b. Alcohol c. Cannabis d. Depressants

a. Opioids produce these physiologic responses. Although alcohol intake can cause euphoria, drowsiness, and slurred speech, the abuser of alcohol develops tolerance and does not usually have these manifestations. Effects of chronic alcohol abuse include impairment of all body systems (see Table 11-7). Cannabis produces euphoria, sedation, and hallucinations. Depressants may cause slurred speech and drowsiness but not euphoria or decreased respirations unless there is an overdose.

Which manifestation(s) is (are) experienced by a patient when withdrawing from sedative-hypnotic addiction (select all that apply)? a. Seizures b. Violence c. Suicidal thoughts d. Tremors and chills e. Sweating, nausea, and cramps

a. Seizures may be experienced with phenobarbital or a long-acting benzodiazepine. Tremors, chills, sweating, nausea, and cramps are seen with opioid withdrawal. Hallucinogens are least likely to have withdrawal symptoms. Suicidal thoughts and violence are more likely to occur in patients withdrawing from stimulants.

Priority Decision: A patient with a history of alcohol abuse is admitted to the hospital following an automobile accident. What is most important for the nurse to assess to plan care for the patient? a. When the patient last had alcohol intake b. How much alcohol has recently been used c. What type of alcohol has recently been ingested d. The patient's current blood alcohol concentration

a. The knowledge of when the patient last had alcohol intake will help the nurse to anticipate the onset of withdrawal symptoms. In patients with alcohol tolerance, the amount of alcohol and the blood alcohol concentration do not reflect impairment as consistently as in the nondrinker. The type of alcohol ingested is not important because in the body it is all alcohol.

4) What are the physiologic effects associated with cocaine and amphetamines select all that apply. a) Drowsiness. b) nasal damage. c) constricted pupils. d) sexual dysfunction. e) increase in appetite. f) tachycardia with hypertension.

b) nasal damage. f) tachycardia with hypertension.

To stop that behavior that leads to the most preventable cause of death in United States, the nurse should support programs that a) prohibit alcohol use in public places. b) prevent put tobacco use in children and adolescents. c) motivate individuals to enter addiction treatment. d) recognize addictions as an illnesses is rather than crimes.

b) prevent put tobacco use in children and adolescents.

The third day after an alcohol dependent patient was admitted to the hospital for acute pancreatitis, the nurse determines at the patient is experiencing alcohol withdrawal delerium. what are the signs of withdrawal delerium on which the nurse base is this judgment select all that apply? a) Apathy. b) seizures. c) disorientation. d) severe depression. e) cardiovascular collapse. f) visual and auditory hallucinations.

b) seizures. c) disorientation. f) visual and auditory hallucinations.

what term is used to describe a decreased effect of a substance following repeated exposure? a) Relapse b) tolerance c) abstinence d) withdrawal

b) tolerance

What are the physiologic effects associated with cocaine and amphetamines (select all that apply)? a. Drowsiness b. Nasal damage c. Sexual arousal d. Constricted pupils e. Increase in appetite f. Tachycardia with hypertension

b, c, f. Cocaine and amphetamines cause nasal damage when snorted, sexual arousal, and tachycardia and hypertension. Drowsiness and constricted pupils are seen with sedative-hypnotics and opioids. There is anorexia with cocaine, not increased appetite.

The third day after an alcohol-dependent patient was admitted to the hospital for pancreatitis, the nurse determines that the patient is experiencing alcohol withdrawal. What are the signs of withdrawal on which the nurse bases this judgment (select all that apply)? a. Apathy b. Seizures c. Gross tremors d. Severe depression e. Cardiovascular collapse f. Visual and auditory hallucinations

b, c, f. Seizures, gross tremors, visual and auditory hallucinations, and alcohol withdrawal delirium are the four major withdrawal syndrome manifestations. Apathy and depression occur in withdrawal from stimulants. Cardiovascular collapse is seen in sedative-hypnotic withdrawal.

To stop the behavior that leads to the most preventable cause of death in the United States, the nurse should support programs that a. prohibit alcohol use in public places. b. prevent tobacco use in children and adolescents. c. motivate individuals to enter addiction treatment. d. recognize addictions as illnesses rather than crimes.

b. Smoking is the single most preventable cause of death and most smokers start smoking by age 16. If smoking in preadolescents and adolescents could be prevented, it is unlikely that these individuals would start smoking at a later age. Health problems associated with smoking and future use of other addictive substances would be significantly reduced

What term is used to describe a decreased effect of a substance following repeated exposure? a. Relapse b. Tolerance c. Abstinence d. Withdrawal

b. Tolerance is described. Relapse is when the person returns to substance use after a period of abstinence. Abstinence is avoidance of substance use. Withdrawal is the response that occurs after abrupt cessation of a substance.

A patient in alcohol withdrawal Has a nursing diagnosis of ineffective Protection related to sensorimotor deficits, seizure activity, and confusion. Which nursing intervention Is most important for the patient? a) Provide a dark and come a quiet environment free from external stimuli. b) Force fluids to assist in diluting the alcohol concentration in the blood. c) Monitor vital signs frequently to detect an extreme autonomic nervous system response. d) Use restraints as necessary to prevent the patient from reacting Violently to hallucinations.

c) Monitor vital signs frequently to detect an extreme autonomic nervous system response.

Which question is the best approach by the nurse to assess in newly admitted patients use of addictive drugs? a) how do you relieve your stress? b) you don't use any illegal drugs do you? c) Which alcohol or recreational drugs do you use d) Do you have any addictions we should know about to prevent complications?

c) Which alcohol or recreational drugs do you use

Priority Decision: A patient in alcohol withdrawal has a nursing diagnosis of ineffective protection related to sensorimotor deficits, seizure activity, and confusion. Which nursing intervention is most important for the patient? a. Provide a darkened, quiet environment free from external stimuli. b. Force fluids to assist in diluting the alcohol concentration in the blood. c. Monitor vital signs frequently to detect an extreme autonomic nervous system response. d. Use restraints as necessary to prevent the patient from reacting violently to hallucinations

c. An extreme autonomic nervous system response may be life threatening and requires immediate intervention. A quiet room is recommended but it should be well lighted to prevent misinterpretation of the environment and visual hallucinations. Cessation of alcohol intake causes low blood alcohol levels leading to withdrawal symptoms and fluids should be administered carefully to prevent dysrhythmias. Patients should not be restrained if at all possible because injury and exhaustion can occur as patients struggle against restraint.

Which question is the best approach by the nurse to assess a newly admitted patient's use of addictive drugs? a. "How do you relieve your stress?" b. "You don't use any illegal drugs, do you?" c. "Which alcohol or recreational drugs do you use?" d. "Do you have any addictions we should know about to prevent complications?"

c. Open-ended questions indicating that substance use is normal or at least understandable are helpful in eliciting information from patients who are reluctant to disclose substance use.

What is an important post operative intervention indicated for the patient with AUD who is alcohol intoxicated and is undergoing emergency surgery? a) Monitor weight because of malnutrition . b) give an emergency dose of IV magnesium. c) Decrease pain medication to prevent cross tolerance to opiates. d) Closely monitor for signs of withdrawal and respiratory and cardiac problems.

d) Closely monitor for signs of withdrawal and respiratory and cardiac problems.

An admission to the hospital for knee replacement, a patient who has smoked for 20 years expresses an interest in quitting. what is the best response by the nurse? a) Good for you! you should talk to your doctor about that. b) Why did you ever start in the 1st place? it's so hard to quit. c) Since you won't be able to smoke while you were in the hospital, just don't start again when you were discharged. d) Great! while you are here, I'll help you make a plan and work with your doctor to get you what you need to quit smoking.

d) Great! while you are here, I'll help you make a plan and work with your doctor to get you what you need to quit smoking.

What is the definition of substance use disorder a) Compulsive need to experience pleasure b) Behavior associated with maintaining an addiction c) Absence of a substance will cause withdrawal symptoms d) Overuse and dependence on a substance that negatively affects functioning

d) Overuse and dependence on a substance that negatively affects functioning

16) The nurses working with a patient at the clinic who does not want to quit smoking even though he is having trouble breathing at times and has a frequent cough. Which clinical practice guideline strategies should the nurse use with this patient. a) Cost, cough, cleanliness, chantix. b) Ask, advise, asses, assist, arrange. c) deduce, describe, decide, deadline. d) Relevance, risks, rewards, roadblocks, repetition

d) Relevance, risks, rewards, roadblocks, repetition

17) When assessing an older patient for substance abuse, the nurse specifically asks the patient about the use of alcohol in which other types of medications? a) Opioids. b) Sedative hypnotics. c) central nervous system stimulants. d) prescription and over the counter medications.

d) prescription and over the counter medications.

What is an important postoperative intervention indicated for the alcoholic patient who is alcohol intoxicated and is undergoing emergency surgery? a. Monitor weight because of malnutrition. b. Give an emergency dose of IV magnesium. c. Decrease pain medication to prevent cross-tolerance to opiates. d. Closely monitor for signs of withdrawal and respiratory and cardiac problems.

d. Alcohol-induced central nervous system (CNS) depression can lead to respiratory and circulatory failure in an alcoholic patient. Vital signs are monitored closely because of the increased risk of infection from malnutrition. Emergency magnesium would not be expected, although an emergency dose of thiamine may have been given before surgery. Pain medication requirements may be increased if the patient is cross-tolerant to opiates.

On admission to the hospital for a knee replacement, a patient who has smoked for 20 years expresses an interest in quitting. What is the best response by the nurse? a. "Good for you! You should talk to your doctor about that." b. "Why did you ever start in the first place? It's so hard to quit." c. "Since you won't be able to smoke while you are in the hospital, just don't start again when you are discharged. d. "Great! I'll help you make a plan and work with your doctor to get you what you need to start while you are here."

d. Nurses have a professional responsibility to help individuals stop smoking. The advice and motivation of health care professionals can be very helpful to the individual. Nurses should encourage and provide information to patients and work with physicians to identify ways to assist patients with quitting.

When assessing an older patient for substance abuse, the nurse specifically asks the patient about the use of alcohol and which other types of medications? a. Opioids b. Sedative-hypnotics c. Central nervous system stimulants d. Prescription and over-the-counter (OTC) medications

d. Older adult patients have the highest use of OTC and prescription drugs, and simultaneous use of these drugs with alcohol is a major problem. Illegal drug use is minimal in older patients except in long-term addicts.

What is the definition of substance abuse? a. A compulsive need to experience pleasure b. Behavior associated with maintaining an addiction c. Absence of a substance will cause withdrawal symptoms d. Overuse and dependence on a substance that negatively affects functioning

d. Substance abuse negatively affects psychologic, physiologic, and/or social functioning of an individual. The compulsive need for pleasure is psychologic dependence. Behavior to maintain addiction is addictive behavior. Absence of a substance causing withdrawal symptoms is physical dependence.