Question 1

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
A) Risk for injury R/T central nervous system stimulation
B) Disturbed thought processes R/T tactile hallucinations
C) Ineffective coping R/T powerlessness over alcohol use
D) Ineffective denial R/T continued alcohol use despite negative consequences

Accepted Answer

The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation.Alcohol withdrawal may include the following symptoms: course tremors of hands,tongue,or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

Question 2

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?
A) Haloperidol (Haldol) and fluoxetine (Prozac)
B) Carbamazepine (Tegretol) and donepezil (Aricept)
C) Disulfiram (Antabuse) and lorazepam (Ativan)
D) Chlordiazepoxide (Librium) and phenytoin (Dilantin)

Accepted Answer

The nurse should anticipate that a physician would order chlordiazepoxide (Librium)and phenytoin (Dilantin)for a client who has a history of complicated withdrawal from benzodiazepines.It is common for long-lasting benzodiazepines to be prescribed for substitution therapy.Phenytoin (Dilantin)is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal.Complicated withdrawals may progress to seizure activity.

Question 3

Which client statement demonstrates positive progress toward recovery from a substance use disorder?
A) "I have completed detox and therefore am in control of my drug use."
B) "I will faithfully attend Narcotic Anonymous (NA) when I can't control my cravings."
C) "As a church deacon, my focus will now be on spiritual renewal."
D) "Taking those pills got out of control. It cost me my job, marriage, and children."

Accepted Answer

A client who takes responsibility for the consequences of substance use is making positive progress toward recovery.This client would most likely be in the working phase of the counseling process,in which he or she accepts the fact that substance use causes problems.

Question 4

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.

Accepted Answer

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.

Question 5

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect.She has been admitted to an inpatient drug rehabilitation program.Which client statement should a nurse associate with a positive prognosis for this client?
A) "I'm not going to use heroin ever again. I know I've got the willpower to do it this time."
B) "I cannot control my use of heroin. It's stronger than I am."
C) "I'm going to get all my children back. They need their mother."
D) "Once I deal with my childhood physical abuse, recovery should be easy."

Accepted Answer

A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control.One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over the substance.

Question 6

A lonely,depressed divorcée has been self-medicating with cocaine for the past year.Which term should a nurse use to best describe this individual's situation?
A) The individual is experiencing psychological addiction.
B) The individual is experiencing physical addiction.
C) The individual is experiencing substance addiction.
D) The individual is experiencing social addiction.

Accepted Answer

The nurse should use the term "psychological addiction" to best describe this client's situation.A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

Question 7

A nurse holds the hand of a client who is withdrawing from alcohol.What is the nurse's 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

Accepted Answer

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.

Question 8

Which term should a nurse use to describe the administration of a central nervous system (CNS)depressant during alcohol withdrawal?
A) Antagonist therapy
B) Deterrent therapy
C) Codependency therapy
D) Substitution therapy

Accepted Answer

A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

Question 9

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

Accepted Answer

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.

Question 10

During group therapy,a client diagnosed with alcohol use disorder states,"I would not have boozed it up if my wife hadn't 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.

Accepted Answer

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.

Question 11

A client's wife has been making excuses for her alcoholic husband's 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?"

Accepted Answer

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.

Question 12

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.

Accepted Answer

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.

Question 13

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.

Accepted Answer

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.

Question 14

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

Accepted Answer

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.

Question 15

Which client statement indicates a knowledge deficit related to substance use?
A) "Although it's legal, alcohol is one of the most widely abused drugs in our society."
B) "Tolerance to heroin develops quickly."
C) "Flashbacks from LSD use may reoccur spontaneously."
D) "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

Accepted Answer

The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless.Both of these substances have potentially harmful effects.Cannabis is the second most widely abused drug in the United States.

Question 16

A nurse evaluates a client's patient-controlled analgesia (PCA)pump and notices 100 attempts within a 30-minute period.Which is the best rationale for assessing this client for substance use disorder?
A) Narcotic pain medication is contraindicated for all clients with active substance-use problems.
B) Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
C) There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction.
D) The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

Accepted Answer

The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.Cross-tolerance occurs when one drug lessens the client's response to another drug.

Question 17

Upon admission for symptoms of alcohol withdrawal,a client states,"I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg,P 110,R 28,and T 97°F (36°C)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

Accepted Answer

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.

Question 18

A client with a history of insomnia has been taking chlordiazepoxide (Librium),15 mg,at night for the past year.The client currently reports that this dose is no longer helping him fall asleep.Which nursing diagnosis appropriately documents this problem?
A) Ineffective coping R/T unresolved anxiety AEB substance abuse
B) Anxiety R/T poor sleep AEB difficulty falling asleep
C) Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
D) Risk for injury R/T addiction to Librium

Accepted Answer

Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

Question 19

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.

Accepted Answer

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.

Question 20

On the first day of a client's alcohol detoxification,which nursing intervention should take priority?
A) Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B) Educate the client about the biopsychosocial consequences of alcohol abuse.
C) Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
D) Administer vitamin B? to prevent Wernicke-Korsakoff syndrome.

Accepted Answer

The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium)in a dosage according to protocol.Chlordiazepoxide (Librium)is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal.Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

Quiz 23: Substance-Related and Addictive Disorders

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?

Which client statement demonstrates positive progress toward recovery from a substance use disorder?

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 mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect.She has been admitted to an inpatient drug rehabilitation program.Which client statement should a nurse associate with a positive prognosis for this client?

A lonely,depressed divorcée has been self-medicating with cocaine for the past year.Which term should a nurse use to best describe this individual's situation?

A nurse holds the hand of a client who is withdrawing from alcohol.What is the nurse's rationale for this intervention?

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?

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?

During group therapy,a client diagnosed with alcohol use disorder states,"I would not have boozed it up if my wife hadn't 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 client's wife has been making excuses for her alcoholic husband's 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 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 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 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?

Which client statement indicates a knowledge deficit related to substance use?

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period.Which is the best rationale for assessing this client for substance use disorder?

Upon admission for symptoms of alcohol withdrawal,a client states,"I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg,P 110,R 28,and T 97°F (36°C) with dry skin,dry mucous membranes,and poor skin turgor.What should be the priority nursing diagnosis?

A client with a history of insomnia has been taking chlordiazepoxide (Librium) ,15 mg,at night for the past year.The client currently reports that this dose is no longer helping him fall asleep.Which nursing diagnosis appropriately documents this problem?

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?

On the first day of a client's alcohol detoxification,which nursing intervention should take priority?