Question 1

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

Accepted Answer

Understanding the connection between alcohol use and life problems is crucial for the client to recognize the impact of their substance use, which is a fundamental step in the recovery process.

Question 2

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?

Accepted Answer

The individual is experiencing psychological dependency, as they are using cocaine to cope with emotional issues like loneliness and depression.

Question 3

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

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 4

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?

Accepted Answer

Intoxication typically occurs at blood alcohol levels of 100 mg/dL or higher. This can result in impaired judgment, decreased coordination, and difficulty with motor skills. However, it is important to note that individuals may experience varying levels of impairment at the same blood alcohol level, as factors such as body size, tolerance, and overall health can affect how alcohol is metabolized in the body.

Question 5

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

Accepted Answer

Administering ordered chlordiazepoxide (Librium) is the priority because it treats the client's alcohol withdrawal symptoms, such as anxiety, agitation, and seizures. Without proper management of withdrawal symptoms, the client is at risk for complications and may be unable to effectively participate in other interventions such as education about the consequences of alcohol abuse or attending Alcoholics Anonymous meetings. Vitamin supplementation may also be appropriate, but it is not the priority intervention on the first day of detoxification.

Question 6

During group therapy, a client diagnosed with chronic alcohol dependence 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?

Accepted Answer

The client is using rationalization by providing an excuse for his alcohol dependence, attributing it to his wife's behavior rather than taking personal responsibility.

Question 7

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response?

Accepted Answer

The nurse should support the client's understanding that her husband is responsible for his own behavior and that she should not enable his drinking by making excuses for him.

Question 8

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 dependence?

Accepted Answer

Clients with a history of substance dependence, particularly on alcohol or benzodiazepines, may develop cross-tolerance to narcotics, requiring higher doses for effective pain management.

Question 9

Which client statement demonstrates positive progress toward recovery from substance abuse?

Accepted Answer

Choice D demonstrates acknowledgement of the negative consequences of substance abuse and a desire to change behavior. The statement also does not suggest that the individual is currently in control of their drug use, indicating a willingness to pursue recovery. Choices A, B, and C either suggest limited commitment to recovery or a belief that control can be maintained without significant behavior change.

Question 10

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

Accepted Answer

Risk for injury is the priority nursing diagnosis for a client experiencing alcohol withdrawal due to the potential for seizures and other dangerous symptoms associated with withdrawal. Disturbed thought processes, ineffective coping, and ineffective denial may also be present, but safety should be the primary concern.

Question 11

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

Accepted Answer

Chlordiazepoxide (Librium) and phenytoin (Dilantin) are commonly used to manage withdrawal symptoms in clients with a history of benzodiazepine use. Chlordiazepoxide is a benzodiazepine that can help alleviate anxiety and prevent seizures during withdrawal, while phenytoin is an anticonvulsant that can also help prevent seizures. These medications should be prescribed and monitored by a healthcare provider with expertise in managing complicated withdrawal.

Question 12

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?

Accepted Answer

Alcohol withdrawal symptoms typically begin within 6-12 hours after the last drink and peak between 24-48 hours. The client's last drink was 1 hour ago and it is currently midnight, so the nurse should expect withdrawal symptoms to begin between 3 a.m. and 11 a.m.

Question 13

A client diagnosed with chronic alcohol dependency 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?

Accepted Answer

Attending 90 AA meetings in 90 days is a common and appropriate goal for individuals newly discharged from inpatient alcohol treatment. It helps establish a routine and provides support from peers who understand the challenges of addiction and recovery. Option B is also a common practice, but it is more appropriate for established members of AA who have already found a sponsor. Option C may be advantageous if the family is supportive and committed to attending meetings, but it is not crucial for successful recovery. Option D is not a typical recommendation of AA, as the focus is on the spiritual and social aspects of recovery rather than medication management.

Question 14

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 substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?

Accepted Answer

The statement "I cannot control my use of heroin. It's stronger than I am." indicates that the client acknowledges the power of addiction and the need for help, which is a positive step towards recovery.

Question 15

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem?

Accepted Answer

The client's reported difficulty falling asleep despite taking the medication for a year suggests the possibility of tolerance to the medication, leading to a disturbed sleep pattern. This diagnosis is appropriate as it reflects the client's current sleep problem while taking the medication. The other options do not fully reflect the client's situation, as there is no evidence of unresolved anxiety, substance abuse, poor sleep due to anxiety, or addiction to Librium that puts the client at risk for injury.

Question 16

A client diagnosed with depression and substance abuse 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?

Accepted Answer

Nonpharmacological interventions such as sleep hygiene education or cognitive-behavioral therapy for insomnia (CBT-i) may be beneficial for the client's altered sleep pattern, and sedative-hypnotics can be potentially addictive and lose their effectiveness due to tolerance.

Question 17

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

Accepted Answer

Substitution therapy involves the administration of medications that mimic the effects of the substance being abused, in order to reduce withdrawal symptoms and cravings. In the case of alcohol withdrawal, CNS depressants like benzodiazepines may be used to alleviate symptoms and prevent seizures. Antagonist therapy involves the use of medications that block the effects of the substance being abused, and is typically used in the maintenance phase of treatment rather than during withdrawal. Deterrent therapy involves pairing a negative consequence with substance use, and is not typically used in the treatment of alcohol withdrawal. Codependency therapy focuses on addressing the behaviors and relationships of individuals who are affected by a loved one's substance use, and is not directly related to the treatment of withdrawal symptoms.

Question 18

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 immediate report to the ED physician?

Accepted Answer

A blood pressure of 180/100 mm Hg is considered hypertensive crisis and requires immediate medical attention, as it can lead to serious complications such as stroke or heart attack. Tactile hallucinations, mood rating, and dehydration are also concerns for a client with a history of heavy alcohol use, but they do not require immediate medical attention as much as hypertensive crisis.

Question 19

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

Accepted Answer

The statement "Marijuana is like smoking cigarettes.Everyone does it.It's essentially harmless." indicates a knowledge deficit related to substance abuse, as it suggests a lack of understanding about the potential harms and risks associated with marijuana use. The other statements demonstrate a basic understanding of the effects of alcohol, heroin, and LSD.

Question 20

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 97S1U1P1$\circ$S1S1P0F (36S1U1P1$\circ$S1S1P0C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?

Accepted Answer

The priority nursing diagnosis in this case is imbalanced nutrition: less than body requirements. The client has not eaten for 3 days and is displaying signs of dehydration such as dry skin, dry mucous membranes, and poor skin turgor. The vital signs are elevated, indicating that the client is in a hypermetabolic state, which can lead to increased nutrient requirements. It is necessary to address the client's nutritional needs before treating the other symptoms of alcohol withdrawal.

Quiz 25: Substance-Related Disorders

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

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?

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?

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

During group therapy, a client diagnosed with chronic alcohol dependence 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, "His problems at work are my fault." Which is the appropriate nursing response?

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 dependence?

Which client statement demonstrates positive progress toward recovery from substance abuse?

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?

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 diagnosed with chronic alcohol dependency 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 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 substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem?

A client diagnosed with depression and substance abuse 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?

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

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 immediate report to the ED physician?

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

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^$\circ$F (36^$\circ$C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?

Quiz 25: Substance-Related Disorders

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

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?

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?

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

During group therapy, a client diagnosed with chronic alcohol dependence 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, "His problems at work are my fault." Which is the appropriate nursing response?

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 dependence?

Which client statement demonstrates positive progress toward recovery from substance abuse?

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?

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 diagnosed with chronic alcohol dependency 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 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 substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem?

A client diagnosed with depression and substance abuse 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?

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

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 immediate report to the ED physician?

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

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 ∘\circ∘ F (36 ∘\circ∘ C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?

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^$\circ$F (36^$\circ$C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?