Substance-Related and Addictive Disorders

In confidence, an emergency department nurse said to a nursing colleague, "I know I am addicted to narcotics but I'm afraid I will lose my nursing license if I talk to my supervisor about it." Select the colleague's best initial response. "For the safety of your patients, you cannot use narcotics anymore. I hope you will get help." "I am glad you were willing to tell me about this problem. Narcotics Anonymous can help you." "There are special programs that can help you with your addiction so you can continue to practice. Talk to your supervisor." "There are many careers where you can use your nursing knowledge but not actually practice nursing. I will be glad to help you find one."

"There are special programs that can help you with your addiction so you can continue to practice. Talk to your supervisor." The colleague should first provide information about programming to give hope to the addicted nurse. Approximately 10% to 15% of nurses have problems related to abuse or addiction. For nurses who are engaging in risk-taking behaviors, there are nonpunitive alternatives to discipline programs in the form of peer assistance. Diversion legislation allows addicted nurses to attend a treatment or recovery program, have their progress monitored, meet specific criteria to return to work, and be spared revocation or suspension of their licenses if they follow the recommendations of their program. After responding, the colleague has a legal responsibility to report this information. p. 423

The nurse is caring for a woman with chronic alcohol intoxication. The woman is prescribed disulfiram to treat the condition. Which information given by the nurse is appropriate about disulfiram? "You may experience adverse effects if you consume alcohol." "You may experience nausea during the course of medication." "You may experience seizures during the course of medication." "You may experience sedation during the course of medication."

"You may experience adverse effects if you consume alcohol." The nurse is caring for a woman with chronic alcohol intoxication. The woman is prescribed disulfiram to treat the condition. Which information given by the nurse is appropriate about disulfiram? "You may experience adverse effects if you consume alcohol." "You may experience nausea during the course of medication." "You may experience seizures during the course of medication." "You may experience sedation during the course of medication."

7. A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

18. A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

19. A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

21. A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

17. A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? A. Antecubital bruising B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

22. A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

28. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three yes answers strongly suggests a problem with alcohol.

13. A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. Which is the appropriate nursing response? A. Why do you assume responsibility for his behaviors? B. Codependency is a typical behavior of spouses of alcoholics. C. Your husband needs to deal with the consequences of his drinking. D. Do you understand what the term enabler means?

ANS: C The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited.

26. A client diagnosed with alcohol use disorder joins a community 12-step program and states, My life is unmanageable. How should the nurse interpret this clients statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

11. Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

15. During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if my wife hadnt been nagging me all the time to get a job. She never did think that I was good enough for her. How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

24. A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. Only oral ingestion of alcohol will cause a reaction when taking this drug. B. It is safe to drink beverages that have only 12% alcohol content. C. This medication will decrease your cravings for alcohol. D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug.

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

16. A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

What is the nurse's most important intervention when caring for a patient experiencing severe alcohol withdrawal symptoms? Administer prescribed appetite stimulants. Administer prescribed hypnotic medication. Administer prescribed antipyretic medication. Administer prescribed anticonvulsant medication.

Administer prescribed anticonvulsant medication. The patient experiencing severe symptoms of alcohol withdrawal will experience generalized seizures, which are managed by administration of prescribed anticonvulsant medication. It is the most important nursing intervention in patients with severe alcohol withdrawal symptoms. Prescribed hypnotic medications are administered to treat insomnia, which is a mild symptom of alcohol withdrawal. Anorexia is also a mild symptom of alcohol withdrawal and can be managed with suitable appetite stimulants. Patients with severe alcohol withdrawal symptoms may experience a high-grade fever, generally above 101° F. The nurse should administer the prescribed antipyretic to reduce the fever. However, it is not the most important intervention. p. 420

A patient is trying to quit the habit of drinking alcohol. Which symptoms does the nurse recognize as the effect of mild alcohol withdrawal? Anorexia Insomnia Restlessness Hypersensitivity Grand mal seizures

Anorexia Insomnia Restlessness Mild alcohol withdrawal occurs as the alcohol concentration in the blood slightly reduces. It can lead to anorexia or loss of appetite, insomnia or lack of sleep, and restlessness. Hypersensitivity to noise and light, and grand mal seizures occur in extreme cases of severe alcohol withdrawal as the alcohol concentration in the blood is greatly reduced. p. 420

Prescription of which medication represents part of an aversive therapy approach to treatment of addiction? Disulfiram Naltrexone Quetiapine fumarate Acamprosate calcium

Disulfiram When taking disulfiram, an individual who ingests alcohol will experience a toxic reaction that causes intense nausea and vomiting, headache, sweating, flushed skin, respiratory difficulties, and confusion. These symptoms are intended to create an aversion to use of alcohol. Quetiapine fumarate, acamprosate calcium, and naltrexone are medications prescribed to reduce discomfort associated with withdrawal. p. 425, Table 22.6

Which medication prescribed to a patient for treatment of alcohol addiction may be associated with intense vomiting, respiratory difficulty, and mental confusion? Disulfiram Phenobarbital Chlordiazepoxide Acamprosate calcium

Disulfiram Disulfiram is used for the maintenance of alcohol abstinence. However, the medication should be taken consistently to maintain the alcohol aversion. Alcohol consumption while on disulfiram leads to a toxic reaction that results in symptoms such as intense nausea, vomiting, respiratory difficulty, and mental confusion. Chlordiazepoxide is used to reduce withdrawal agitation and can cause sedation and seizures. Phenobarbital could result in sedation. Acamprosate calcium causes side effects such as itching, diarrhea, and intestinal gas. p. 425, Table 22.6

Which type of facility would best support the needs of an impaired patient who is need of long-term help related to hallucinogen abuse? Halfway house Partial hospitalization Intensive outpatient program Residential rehabilitation center

Residential rehabilitation center A patient with severe impairment as a result of hallucinogen abuse can receive long-term professional medical care in a residential rehabilitation center. Residents of halfway houses reside at the house but continue working outside. These patients may be more vulnerable to relapse. Partial hospitalization provides a combination of psychotherapy and educational groups without having to reside at the hospital but is not the best support for the patient who is severely impaired. An intensive outpatient program is a nonresidential setup that only provides medication oversight, and this would not be the best choice to a patient who is severely impaired. p. 427

When caring for a patient who is intoxicated from alcohol, which need has the highest priority? Self-esteem needs Safety and security Physiologic stability Cultural preferences

Safety and security The plan should address safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and cultural needs. Safety is the highest priority because of the patient's imminent risks for injury while intoxicated. Physiologic stability has the second highest priority. p. 424

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? Supervisory staff should be informed as soon as possible in both cases. Neither should be reported until the nurse has collected factual evidence. No report should be made until suspicions are confirmed by a second staff member. 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.

Supervisory staff should be informed as soon as possible in both cases. 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 coworkers 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 a 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. p. 423

What information is important for the nurse to understand when initiating the use of naltrexone prescribed for alcohol relapse prevention? The tablets will be taken three times a day. Medication can begin on the fifth day of abstinence from alcohol. The patient needs to be opiate-free for 10 days before starting the medication. The patient must avoid all alcohol and substances such as cough syrup and mouthwash containing alcohol.

The patient needs to be opiate-free for 10 days before starting the medication. It is important that the nurse ensure the patient is opiate-free for 10 days before starting naltrexone for alcohol relapse prevention. Acamprosate calcium tablets are taken three times a day and initiated on the fifth day of abstinence from alcohol. The patient prescribed disulfiram should avoid all alcohol and substances such as cough syrup and mouthwash containing alcohol. p. 425

Dan begins attendance at AA meetings. Which of the statements by Dan reflects the purpose of the organization? a. "They claim they will help me stay sober." b. "I'll dry out in AA, then I can have a social drink now and then." c. "AA is only for people who have reached the bottom." d. "If I lost my job, AA will help me find another."

a. "They claim they will help me stay sober."

Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job, states to the nurse, "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed anymore days than my coworkers." Which defense mechanism is Dan using? a. Denial b. Projection c. Displacement d. Rationalization

a. Denial

Mr. White is admitted to the hospital after an extended period of binge alcohol drinking. His wife reports that he has been a heavy drinking for a number of years. Laboratory reports reveal he has a blood alcohol level of 250 mg/dL. He is placed on the chemical addiction unit for detoxification. When would the first signs of alcohol withdrawal symptoms be expected to occur? a. Several hours after the last drink b. 2 to 3 days after the last drink c. 4 to 5 days after the last drink d. 6 to 7 days after the last drink

a. Several hours after the last drink

Symptoms of alcohol withdrawal include: a. Euphoria, hyperactivity, and insomnia. b. Depression, suicidal ideation, and hypersomnia. c. Diaphoresis, nausea and vomiting, and tremors. d. Unsteady gait, nystamus, and profound disorientation.

c. Diaphoresis, nausea and vomiting, and tremors.

Dan has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job. Dan's drinking buddies come for a visit, and when they leave, the nurse smells alcohol on Dan's breath. Which of the following would be the best intervention with Dan at this time? a. Search his room for evidence. b. Ask, "Have you been drinking alcohol, Dan?" c. Send a urine specimen from Dan to the laboratory for drug screening. d. Tell Dan, "These guys cannot come to the unit to visit you again."

c. Send a urine specimen from Dan to the laboratory for drug screening.