Addictions and Compulsions

MULTIPLE CHOICE

1. A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
c. About 0200 on hospital day 3 (72 hours after drinking stopped)
d. About 0200 on hospital day 4 (96 hours after drinking stopped)
ANS: B
Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

DIF: Cognitive Level: Application (Applying) REF: Pages: 372-373
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is:
a. jaundiced.
b. dependent on alcohol.
c. healthy but underweight.
d. microcephalic and cognitively impaired.
ANS: D
Fetal alcohol syndrome is the result of alcohol’s inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors.

DIF: Cognitive Level: Application (Applying) REF: Page: 369
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck’s traction and screams, “Somebody tied me up with ropes.” The patient is experiencing:
a. an illusion.
b. a delusion.
c. hallucinations.
d. hypnagogic phenomenon.
ANS: A
The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 373
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, “Snakes are crawling on my bed. I’ve got to get out of here.” What is the most accurate assessment of the situation? The patient:
a. is attempting to obtain attention by manipulating staff.
b. may have sustained a head injury before admission.
c. has symptoms of alcohol withdrawal delirium.
d. is having a recurrence of an acute psychosis.
ANS: C
Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

DIF: Cognitive Level: Application (Applying) REF: Pages: 372-373
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
a. Disturbed sensory perception
b. Ineffective coping
c. Ineffective denial
d. Risk for injury
ANS: D
clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 372-373 | Page: 386
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Physiological Integrity

6. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine
ANS: C
This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patient’s symptoms.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 373
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

7. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit.
ANS: C
This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patient’s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 372-373 | Page: 385
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

8. A patient with a history of daily alcohol abuse says, “Drinking helps me cope with being a single parent.” Which response by the nurse would help the individual conceptualize the drinking more objectively?
a. “Sooner or later, alcohol will kill you. Then what will happen to your children?”
b. “I hear a lot of defensiveness in your voice. Do you really believe this?”
c. “If you were coping so well, why were you hospitalized again?”
d. “Tell me what happened the last time you drank.”
ANS: D
The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Pages: 385-386 | Pages: 388-389 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

9. A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse’s best response?
a. “It is a self-help group with the goal of sobriety.”
b. “It is a form of group therapy led by a psychiatrist.”
c. “It is a group that learns about drinking from a group leader.”
d. “It is a network that advocates strong punishment for drunk drivers.”
ANS: A
AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 385-387 | Page: 391
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

10. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has recently ingested both alcohol and sedative drugs.
ANS: B
A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient’s body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 371-372
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. A patient admitted to an alcoholism rehabilitation program says, “I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening.” The patient is using which defense mechanism?
a. Rationalization
b. Introjection
c. Projection
d. Denial
ANS: D
Minimizing one’s drinking is a form of denial of alcoholism. The patient’s own description indicates that “social drinking” is not an accurate name for the behavior. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one’s own system.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 384-385 | Pages: 388-389
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

12. A new patient in an alcoholism rehabilitation program says, “I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening.” Which response by the nurse will help the patient view the drinking more honestly?
a. “I see,” and use interested silence.
b. “I think you may be drinking more than you report.”
c. “Being a social drinker involves having a drink or two once or twice a week.”
d. “You describe drinking steadily throughout the day and evening. Am I correct?”
ANS: D
The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 385-389
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, “After discharge, I’m sure everything will be just fine.” Which remark by the nurse will be most helpful to the spouse?
a. “It is good that you’re supportive of your spouse’s sobriety and want to help maintain it.”
b. “Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.”
c. “It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.”
d. “Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse’s behavior carefully.”
ANS: B
During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 370-371 | Pages: 390-391 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

14. The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?
a. Consider each disorder primary and provide simultaneous treatment.
b. The person will benefit from treatment in a residential treatment facility.
c. Withdraw the person from cannabis, and then treat the schizophrenia.
d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
ANS: A
Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 390
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

15. When working with a patient beginning treatment for alcohol abuse, what is the nurse’s most therapeutic approach?
a. Empathetic, supportive
b. Strong, confrontational
c. Skeptical, guarded
d. Cool, distant
ANS: A
Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 384-385 | Pages: 388-389 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should:
a. explore the patient’s reasons for drinking today.
b. arrange admission to an inpatient psychiatric unit.
c. coordinate emergency admission to a detoxification unit.
d. tell the patient, “We cannot see you today because you’ve been drinking.”
ANS: D
One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary.

DIF: Cognitive Level: Application (Applying) REF: Pages: 385-391
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur?
a. Tolerance develops.
b. The alcohol is less potent.
c. Antagonistic effects occur.
d. Hypomagnesemia develops.
ANS: A
Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 370
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

18. Which statement most accurately describes substance addiction?
a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped.
b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters.
c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects.
d. It involves using a combination of substances to weaken or inhibit the effect of another drug.
ANS: A
Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped.

DIF: Cognitive Level: Knowledge (Remembering) REF: Page: 363
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, “I feel terrible.” Which analysis is correct?
a. The patient is exhibiting a prodromal symptom of seizures.
b. An idiosyncratic reaction to naloxone is occurring.
c. Symptoms of opiate withdrawal are present.
d. The patient is experiencing a relapse.
ANS: C
The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 375-376
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

20. In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department.
c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
d. The patient will identify two community resources for the treatment of substance abuse by discharge.
ANS: A
Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 375-376 | Pages: 385-386 TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Physiological Integrity

21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose.
a. Monitor the airway and vital signs every 15 minutes.
b. Insert a nasogastric tube and test gastric pH.
c. Treat hyperpyrexia with cooling measures.
d. Insert an indwelling urinary catheter.
ANS: A
Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 375-376 | Pages: 385-386 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse’s drug use was evident?
a. Accepting responsibility for medication errors.
b. Seeking to be assigned as a medication nurse.
c. Frequent complaints of physical pain.
d. High sociability with peers.
ANS: B
The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility.

DIF: Cognitive Level: Application (Applying) REF: Pages: 369-370
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

23. A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling?
a. Conveying understanding that pressures associated with nursing practice underlie substance abuse.
b. Pointing out that work problems are the result, but not the cause, of substance abuse.
c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing.
d. Providing health teaching about stress management.
ANS: A
Enabling denies the seriousness of the patient’s problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

DIF: Cognitive Level: Application (Applying) REF: Pages: 369-371
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

24. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed?
a. One-week detoxification program
b. Long-term outpatient therapy
c. Twelve-step self-help program
d. Residential program
ANS: D
Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

DIF: Cognitive Level: Application (Applying) REF: Page: 391
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

25. Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis?
a. Powerlessness
b. Disturbed thought processes
c. Ineffective thermoregulation
d. Impaired oral mucous membrane
ANS: B
Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 386
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
a. Make physical contact by frequently touching the patient.
b. Offer intellectual activities requiring concentration.
c. Avoid manipulation by denying the patient’s requests.
d. Observe for depression and suicidal ideation.
ANS: D
Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 376-377 | Pages: 385-387 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment

27. Which assessment findings best correlate to the withdrawal from central nervous system depressants?
a. Dilated pupils, tachycardia, elevated blood pressure, elation
b. Labile mood, lack of coordination, fever, drowsiness
c. Nausea, vomiting, diaphoresis, anxiety, tremors
d. Excessive eating, constipation, headache
ANS: C
The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 372 | Pages: 375-376
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
a. Substance abuse
b. Substance addiction
c. Substance intoxication
d. Recreational use of a social drug
ANS: B
Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 363-364 | Page: 366
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

29. Which assessment findings will the nurse expect in an individual who has just injected heroin?
a. Anxiety, restlessness, paranoid delusions
b. Heightened sexuality, insomnia, euphoria
c. Muscle aching, dilated pupils, tachycardia
d. Drowsiness, constricted pupils, slurred speech
ANS: D
Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse.

DIF: Cognitive Level: Application (Applying) REF: Page: 367 | Pages: 371-372
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for:
a. slurred speech, excessive drowsiness, and bradycardia.
b. paranoid delusions, tactile hallucinations, and panic.
c. runny nose, yawning, insomnia, and chills.
d. anxiety, agitation, and aggression.
ANS: C
Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

DIF: Cognitive Level: Application (Applying) REF: Pages: 371-372
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

31. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled “pentobarbital sodium.” What is the nurse’s first action?
a. Test reflexes
b. Check pupils
c. Initiate vomiting
d. Establish a patent airway
ANS: D
Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

DIF: Cognitive Level: Application (Applying) REF: Pages: 371-372 | Page: 385
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

32. An adult in the emergency department states, “I feel restless. Everything I look at wavers. Sometimes I’m outside my body looking at myself. I hear colors. I think I’m losing my mind.” Vital signs are slightly elevated. The nurse should suspect a:
a. cocaine overdose.
b. schizophrenic episode.
c. phencyclidine (PCP) intoxication.
d. D-lysergic acid diethylamide (LSD) ingestion.
ANS: D
The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going “crazy.” Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

DIF: Cognitive Level: Application (Applying) REF: Pages: 379-380
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

33. In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)?
a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided.
b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained.
c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided.
d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
ANS: A
Patients who have ingested LSD respond well to being “talked down” by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Pages: 379-381 | Pages: 385-386 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment

34. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect:
a. acrophobia.
b. hypothermia.
c. hallucinations.
d. anterograde amnesia.
ANS: D
Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 378-379
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

35. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, “Often my friend drinks, along with taking more of the drug than is prescribed.” What is the effect of the use of alcohol with this drug?
a. The drug’s metabolism is stimulated.
b. The drug’s effect is diminished.
c. A synergistic effect occurs.
d. There is no effect.
ANS: C
Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 330-371
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

36. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction?
a. methadone (Dolophine)
b. bromocriptine (Parlodel)
c. disulfiram (Antabuse)
d. naltrexone (Revia)
ANS: D
Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 373-375 | Pages: 380-381 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

37. Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will
a. use rationalization in healthy ways.
b. state, “I see the need for ongoing treatment.”
c. identify constructive outlets for expression of anger.
d. develop a trusting relationship with one staff member.
ANS: B
The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Pages: 384-385 | Pages: 387-392 TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Psychosocial Integrity

38. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
a. “Have you ever had blackouts?”
b. “When did you have your last drink?”
c. “Has drinking caused you any problems?”
d. “When did you decide to seek treatment?”
ANS: B
Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority.

DIF: Cognitive Level: Application (Applying) REF: Pages: 381-385
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

39. A patient in an alcohol treatment program says, “I have been a loser all my life. I’m so ashamed of what I have put my family through. Now, I’m not even sure I can succeed at staying sober.” Which nursing diagnosis applies?
a. Chronic low self-esteem
b. Situational low self-esteem
c. Disturbed personal identity
d. Ineffective health maintenance
ANS: A
Low self-esteem is present when a patient sees himself or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 385-386 | Pages: 387-391
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

40. Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective?
a. Is abstinent for 10 days and states, “I can maintain sobriety one day at a time.” Spoke with employer, who is willing to allow the patient to return to work in three weeks.
b. Is abstinent for 15 days and states, “My problems are under control.” Plans to seek a new job where co-workers will not know history.
c. Attends AA daily; states many of the members are “real” alcoholics and says, “I may be able to help some of them find jobs at my company.”
d. Is abstinent for 21 days and says, “I know I can’t handle more than one or two drinks in a social setting.”
ANS: A
The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 387-391
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

41. Which assessment findings support a nurse’s suspicion that a patient has been using inhalants?
a. Pinpoint pupils and respiratory rate of 12 breaths per minute
b. Perforated nasal septum and hypertension
c. Drowsiness, euphoria, and constipation
d. Confusion, mouth ulcers, and ataxia
ANS: D
Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid abuse.

DIF: Cognitive Level: Application (Applying) REF: Pages: 381-382
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply.
a. Avoid aged cheeses.
b. Read labels of all liquid medications.
c. Wear sunscreen and avoid bright sunlight.
d. Maintain an adequate dietary intake of sodium.
e. Avoid breathing fumes of paints, stains, and stripping compounds.
ANS: B, E
The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol.

DIF: Cognitive Level: Application (Applying) REF: Pages: 373-374
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

2. A nurse can assist a patient diagnosed with addiction and the patient’s family in which aspects of relapse prevention? Select all that apply.
a. Rehearsing techniques to handle anticipated stressful situations
b. Advising the patient to accept residential treatment if relapse occurs
c. Assisting the patient to identify life skills needed for effective coping
d. Isolating self from significant others and social situations until sobriety is established
e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances
ANS: A, C, E
Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations. The nurse can participate in role playing and help the patient evaluate the usefulness of new strategies. The nurse can also provide valuable information about the physiologic changes that can be expected and the ways in which to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

DIF: Cognitive Level: Application (Applying) REF: Page: 385 | Pages: 387-391
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

3. While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply.
a. Administration of naloxone (Narcan)
b. Vitamin B12 and folate supplements
c. Restoring nutritional integrity
d. Prevention of seizures
e. Reduction of fever
ANS: D, E
Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 376-377 | Pages: 385-386 TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity