Question 1

Which term should the nurse use to describe the administration of a CNS depressant during alcohol withdrawal?

Accepted Answer

Substitution therapy is the administration of a safer drug to manage the withdrawal symptoms of a more dangerous drug. In this case, a CNS depressant is being used to treat the withdrawal symptoms of alcohol, which is also a CNS depressant. Antagonist therapy involves using a medication to block the effects of a drug, deterrent therapy involves making a person associate a negative experience with taking a drug, and codependency therapy involves treating the family members and loved ones of a person struggling with addiction.

Question 2

A lonely,depressed divorcée has been self-medicating with cocaine for the past year.Which term does the nurse identify that best describes the client's situation?

Accepted Answer

The term "psychological addiction" refers to the emotional or mental dependence on a substance, which aligns with the client's use of cocaine to self-medicate for loneliness and depression.

Question 3

The nurse is reviewing STAT laboratory data of a client presenting in the ED.What is the minimum blood alcohol level at which should the nurse expects intoxication to occur?

Accepted Answer

The minimum blood alcohol level at which intoxication can occur varies from person to person depending on body weight, gender, and tolerance. However, in general, a blood alcohol level of 100 mg/dL or higher is considered to indicate intoxication.

Question 4

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)is most appropriate for the nurse to discuss with the client during discharge teaching?

Accepted Answer

Attending 90 AA meetings in 90 days is a common goal for individuals in early recovery from alcohol use disorder, as it helps to establish a support system and create a consistent routine. It also helps to reinforce the importance of ongoing sobriety efforts. While relying on an AA sponsor (B) and incorporating family in AA attendance (C) are also important aspects of AA, they may not be appropriate for all clients or may not be the primary focus during initial discharge teaching. Seeking deterrent medications through AA (D) is not typically a goal of AA and may be more appropriate for a discussion with a healthcare provider.

Question 5

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?

Accepted Answer

A blood pressure of 180/100 mm Hg is very high and could be a sign of alcohol withdrawal. This is a medical emergency that requires immediate attention by the physician. Antecubital bruising may be concerning for IV drug use, but it is not an immediate emergency. A mood rating of 2/10 may indicate depression or anxiety, but it is not urgent. Dehydration is a common complication of alcohol use, but it is not an immediate emergency unless the client is severely dehydrated.

Question 6

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 indicates to the nurse that the client has a positive prognosis?

Accepted Answer

Acknowledging the lack of control over heroin use is a crucial step in recovery, as it indicates the client recognizes the power of addiction and the need for help.

Question 7

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

Accepted Answer

Option D demonstrates acknowledgement of the negative consequences of substance use and the desire to make positive changes in their life. This is a key step in recovery from a substance use disorder. Option A shows a false sense of control while option B relies solely on attending meetings and may not address underlying issues. Option C focuses on spiritual renewal but does not address the substance use disorder directly.

Question 8

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

Accepted Answer

The client's statement that everyone smokes marijuana and that it is harmless indicates a knowledge deficit related to substance use. This statement is false and demonstrates a lack of understanding about the potential risks and negative consequences of using marijuana.

Question 9

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 the nurse should encourage the client to try nonpharmacological interventions first?

Accepted Answer

Sedative-hypnotics have a high potential for addiction and tolerance, meaning that they will lose their effectiveness over time, and the client will require higher doses to achieve the same effect. Therefore, nonpharmacological interventions such as cognitive-behavioral therapy (CBT) and sleep hygiene should be tried before resorting to medications with a high risk of addiction.

Question 10

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

Accepted Answer

Chlordiazepoxide (Librium) is a benzodiazepine used for detoxification from benzodiazepine dependence. Phenytoin (Dilantin) is an anticonvulsant that can be used to prevent seizures that may occur during withdrawal. Together, they can be used to manage withdrawal symptoms in a client with a history of complicated withdrawal from benzodiazepines. The other answer choices do not directly address benzodiazepine withdrawal.

Question 11

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

Accepted Answer

The client's reported difficulty falling asleep despite their long-term use of chlordiazepoxide (Librium) suggests that they have developed tolerance to the medication, which has resulted in a disturbed sleep pattern. This diagnosis accurately reflects the client's current condition and precipitating factors. Ineffective coping (choice A) may be present but is not the most accurate diagnosis in this case. Anxiety (choice B) is a symptom rather than a nursing diagnosis. Risk for injury (choice D) is not supported by the given information.

Question 12

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

Accepted Answer

Holding the hand of a client withdrawing from alcohol allows the nurse to assess for fine tremors, which are a common symptom of alcohol withdrawal.

Question 13

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.Which of the following is the priority nursing diagnosis?

Accepted Answer

The client's symptoms, including not eating for 3 days, dry skin, dry mucous membranes, and poor skin turgor, indicate dehydration and malnutrition, making "Imbalanced nutrition: less than body requirements" the priority nursing diagnosis.

Question 14

The 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?

Accepted Answer

Clients who regularly use alcohol, benzodiazepines, or other substances may have developed cross-tolerance to analgesics, meaning they require increased doses to achieve effective pain control. The high number of attempts within a 30-minute period could indicate that the client is seeking excessive amounts of medication, indicating potential substance use disorder. It's important to assess the client for substance use disorder to ensure they receive appropriate treatment and pain management.

Question 15

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?

Accepted Answer

The appropriate response is to help the wife understand that her husband needs to face the consequences of his actions, which can encourage healthier boundaries and reduce enabling behavior.

Question 16

The nurse is interviewing a client in an outpatient drug treatment clinic.To promote success in the recovery process,which initial outcome should the nurse expect the client to accomplish?

Accepted Answer

While all of the options may be important for recovery, correlating life problems with alcohol use is a fundamental step in recognizing triggers and developing coping mechanisms. This can help the client avoid relapse and make progress towards a successful recovery. Identifying a support person and giving up old drinking buddies are also important, but they are secondary goals that can come later in the recovery process. Verbalizing the effects of alcohol on the body is important, but it is also more of an educational goal rather than a practical step towards recovery.

Question 17

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 the nurse interpret this statement?

Accepted Answer

The client is using rationalization, a defense mechanism, by providing a seemingly reasonable excuse or explanation for his behavior (alcohol use) that is actually not the real reason, to justify his alcohol dependence and avoid facing the true issues.

Question 18

A client has a history of daily bourbon drinking for the past 6 months.He is brought to an ED by family,who report that his last drink was 1 hour ago.It is now 12 midnight.When will the nurse expect this client to exhibit withdrawal symptoms?

Accepted Answer

According to the Clinical Institute Withdrawal Assessment for Alcohol (CIWA), withdrawal symptoms typically begin 6-8 hours after the last drink, and peak between 24 and 48 hours. Therefore, based on the client's history and time since last drink, the nurse would expect withdrawal symptoms to begin between 3 a.m. and 11 a.m.

Question 19

Which is the priority nursing diagnosis for a client experiencing alcohol withdrawal?

Accepted Answer

Risk for injury related to central nervous system stimulation is the priority nursing diagnosis for a client experiencing alcohol withdrawal. Alcohol withdrawal can cause seizures, which can lead to injury, so preventive measures may be necessary. Close monitoring is also essential because withdrawal symptoms can escalate rapidly, and rapid treatment may be necessary.

Question 20

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

Accepted Answer

Administering ordered chlordiazepoxide (Librium) is the priority on the first day of alcohol detoxification as it helps manage symptoms of alcohol withdrawal, including seizures and delirium tremens. This medication should only be given as ordered by the physician and according to protocol. Encouraging attendance at Alcoholics Anonymous meetings, educating the client about the consequences of alcohol abuse, and administering vitamin B1 to prevent Wernicke-Korsakoff syndrome are all important interventions, but they should not take priority over managing withdrawal symptoms with medication.

Quiz 23: Substance-Related and Addictive Disorders