Question 1

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.

Accepted Answer

The priority outcome in an emergency situation is to stabilize the patient's vital signs to ensure immediate survival and prevent further complications.

Question 2

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?

Accepted Answer

Tolerance has developed, meaning that over time, the patient's body has adapted to the presence of alcohol, requiring more of it to achieve the same effects.

Question 3

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?

Accepted Answer

The spouse's actions reflect codependence, where they take on responsibilities and enable the partner's behavior, often neglecting their own needs.

Question 4

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?

Accepted Answer

One-on-one supervision is the best choice as the patient is experiencing hallucinations and is fearful, agitated, and diaphoretic. The patient may need help staying oriented and safe. Checking on the patient every 15 minutes may not be enough, and keeping the room dimly lit may exacerbate the patient's fears. Forcing fluids may not be the priority intervention at this time.

Question 5

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?

Accepted Answer

Naltrexone is used to maintain abstinence in patients with addiction to both alcohol and opioids, as it blocks the euphoric effects of these substances.

Question 6

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response.

Accepted Answer

Encouraging family members to make their loved one responsible for the consequences of their behavior supports accountability and promotes personal responsibility, which are important aspects of recovery.

Question 7

Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose?

Accepted Answer

A therapeutic milieu for a patient with a hallucinogen overdose should be simple and safe to reduce sensory overload and provide a calming environment.

Question 8

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.

Accepted Answer

The symptoms described, such as shakiness, irritability, anxiety, sweating, nightmares, hallucinations, and a high pulse rate, are indicative of alcohol-withdrawal delirium, which can occur in patients who have been drinking heavily and then suddenly stop.

Question 9

Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia 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?

Accepted Answer

The blood alcohol level of 0.50 mg% is relatively low, yet the patient is showing significant signs of intoxication such as ataxia and slurred speech. This suggests that the patient has a high tolerance to alcohol, as someone with low tolerance would typically show these symptoms at a higher blood alcohol level.

Question 10

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority?

Accepted Answer

Respiratory assessment has the highest priority in a patient with an opioid overdose because opioids can suppress the respiratory drive and lead to respiratory depression, which can quickly escalate to respiratory arrest and death. Therefore, the nurse should closely monitor the patient's respiratory rate, depth, and effort, as well as oxygen saturation levels to identify any signs of respiratory distress or failure. Cardiovascular, neurologic, and hepatic assessments are also important but are secondary to respiratory assessment.

Question 11

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?

Accepted Answer

Benzodiazepines are commonly prescribed to manage alcohol withdrawal symptoms, including anxiety, agitation, and hallucinations.

Question 12

A patient asks for information about Alcoholics Anonymous. Select the nurse's best response.

Accepted Answer

Alcoholics Anonymous (AA) is a self-help group whose primary purpose is to help its members achieve and maintain sobriety. It is not led by a psychiatrist, does not focus on learning about drinking from a leader, and does not advocate for punishment of drunk drivers.

Question 13

A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response.

Accepted Answer

AA provides a supportive environment where individuals work through a 12-step program with peer support.

Question 14

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?

Accepted Answer

The priority nursing diagnosis is Risk for injury because the patient is agitated and may attempt to get out of the bed or harm themselves while trying to get rid of the perceived bugs. It is important to keep the patient safe while addressing their disturbed sensory perception and ineffective coping.

Question 15

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 and76 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?

Accepted Answer

The increasing blood pressure and pulse readings may be indicative of worsening physical condition or potential complications related to the injury or intoxication. Consulting the health care provider is necessary to determine the appropriate course of action. Forced fluids, a clean-catch urine sample, or a vest-type restraint may not be the priority action in this situation.

Question 16

Select the most therapeutic manner for a nurse to work with a patient who is beginning treatment for alcohol addiction.

Accepted Answer

An empathetic, supportive approach is therapeutic as it helps build trust and encourages the patient to engage in treatment.

Question 17

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?

Accepted Answer

Asking the patient to describe what happened the last time they drank can help them objectively reflect on the consequences of their behavior. It can also help them see patterns in their drinking behavior and how it may not actually be helping them cope in the long run.

Question 18

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?

Accepted Answer

The patient is using denial as a defense mechanism by minimizing or refusing to acknowledge the extent of their drinking problem, despite evidence to the contrary.

Question 19

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?

Accepted Answer

While sobriety can solve some problems, it is important for the spouse to understand that new challenges may arise as the patient adjusts to a life without substances. This realistic perspective can help the spouse prepare for potential difficulties and support the patient effectively.

Question 20

The treatment team discusses the plan of care for a patient with concurrent disorders of schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, which of the following should the team do?

Accepted Answer

Simultaneous treatment of both schizophrenia and substance abuse is essential because each condition can exacerbate the other, and addressing both concurrently can lead to better overall outcomes.

Quiz 18: Psychoactive Substance Use and Treatment