Substance Use and Addictive Disorders

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
1. Risk for injury R/T central nervous system stimulation
2. Disturbed thought processes R/T tactile hallucinations
3. Ineffective coping R/T powerlessness over alcohol use
4. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: 1
Rationale: 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; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

Cognitive Level: Analysis
Integrated Process: Diagnosis

2. 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 addiction?
1. Narcotic pain medication is contraindicated for all clients with active substance use disorders.
2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control.
3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance.
4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

ANS: 2
Rationale: The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

Cognitive Level: Application
Integrated Process: Evaluation

3. On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?
1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days.
2. Educate the client about the biopsychosocial consequences of alcohol abuse.
3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: 3
Rationale: The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

Cognitive Level: Application
Integrated Process: Implementation

4. Which client statement indicates a knowledge deficit related to a substance use disorder?
1. “Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
2. “Tolerance to heroin develops quickly.”
3. “Flashbacks from LSD use may reoccur spontaneously.”
4. “Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”

ANS: 4
Rationale: The nurse should determine that the client has a knowledge deficit related to substance use disorders when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

Cognitive Level: Application
Integrated Process: Evaluation

5. A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual’s situation?
1. Psychological addiction
2. Physical addiction
3. Substance induced disorder
4. Social induced disorder

ANS: 1
Rationale: The nurse should use the term psychological addiction to best describe the client’s situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort.

Cognitive Level: Application
Integrated Process: Assessment

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal?
1. Antagonist therapy
2. Deterrent therapy
3. Codependency therapy
4. Substitution therapy

ANS: 4
Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

Cognitive Level: Application
Integrated Process: Assessment

7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to AA, would be most appropriate for a nurse to discuss with the client during discharge teaching?
1. After discharge, the client will immediately attend 90 AA meetings in 90 days.
2. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
3. After discharge, the client will incorporate family in AA attendance.
4. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: 1
Rationale: 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 alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure.

Cognitive Level: Application
Integrated Process: Implementation

8. 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 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse’s first priority?
1. Hearing and visual impairment
2. Blood pressure of 180/100 mm Hg
3. Mood rating of 2/10 on numeric scale
4. Dehydration

ANS: 2
Rationale: The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use.

Cognitive Level: Analysis
Integrated Process: Implementation

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

ANS: 4
Rationale: A client who takes responsibility for the consequences of substance use disorder or substance addiction is making positive progress toward recovery. This would indicate completion of the first step of a 12-step program.

Cognitive Level: Application
Integrated Process: Evaluation

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s rationale for this intervention?
1. To assess for emotional strength
2. To assess for Wernicke-Korsakoff syndrome
3. To assess for tachycardia
4. To assess for fine tremors

ANS: 4
Rationale: 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, and coarse tremors.

Cognitive Level: Analysis
Integrated Process: Assessment

11. A client presents with symptoms of alcohol withdrawal and states, “I haven’t eaten in three days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis?
1. Knowledge deficit
2. Fluid volume excess
3. Imbalanced nutrition: less than body requirements
4. Ineffective individual coping

ANS: 3
Rationale: 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.

Cognitive Level: Analysis
Integrated Process: Diagnosis

12. 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?
1. “Why do you assume responsibility for his behaviors?”
2. “I think you should start to confront his behavior.”
3. “Your husband needs to deal with the consequences of his drinking.”
4. “Do you understand what the term enabler means?”

ANS: 3
Rationale: The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client’s wife may be in denial and enabling the husband’s behavior. Codependency is a typical behavior of spouses of alcoholics. Partners of clients with substance addiction must come to realize that the only behavior they can control is their own.

Cognitive Level: Application
Integrated Process: Implementation

13. Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium?
1. Haloperidol (Haldol) and fluoxetine (Prozac)
2. Carbamazepine (Tegretol) and donepezil (Aricept)
3. Disulfiram (Antabuse) and lorazepan (Ativan)
4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: 4
Rationale: The nurse should anticipate that a physician would order chlordiazepoxide and phenytoin for a client who has a history of benzodiazepine withdrawal delirium. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin is an anticonvulsant used to prevent seizures.

Cognitive Level: Application
Integrated Process: Assessment

14. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
1. The client will identify one person to turn to for support.
2. The client will give up all old drinking buddies.
3. The client will be able to verbalize the effects of alcohol on the body.
4. The client will correlate life problems with alcohol use.

ANS: 4
Rationale: The nurse should expect that the client would initially correlate life problems with alcohol addiction. Acceptance of the problem is the first part of the recovery process.

Cognitive Level: Application
Integrated Process: Planning

15. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
1. 50 mg/dL
2. 100 mg/dL
3. 250 mg/dL
4. 300 mg/dL

ANS: 2
Rationale: 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.

Cognitive Level: Application
Integrated Process: Evaluation

16. A client diagnosed with major depressive episode 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?
1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance.
2. Sedative-hypnotics are expensive and have numerous side effects.
3. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

ANS: 1
Rationale: The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological addiction.

Cognitive Level: Application
Integrated Process: Implementation

17. A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the client’s physician to treat this disorder. The nurse would give the client information on which medications?
1. Escitalopram (Lexapro) and clozapine (Clozaril)
2. Citalopram (Celexa) and olanzapine (Zyprexa)
3. Lithium carbonate (Lithobid) and sertraline (Zoloft)
4. Naltrexone (ReVia) and ziprasidone (Geodon)

ANS: 3
Rationale: The SSRIs and clomipramine have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. Lithium, carbamazepine, and naltrexone have also been shown to be effective. The antipsychotic medications clozapine, olanzapine, and ziprasidone are not treatments of choice for this disorder.

Cognitive Level: Application
Integrated Process: Implementation

18. A nurse is assessing a pathological gambler. What would differentiate this client’s behaviors from the behaviors of a non-pathological gambler?
1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not.
2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men.
3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course.
4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief.

ANS: 1
Rationale: There is a correlation between pathological gambling and abnormalities in the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. This is not the case with non-pathological gambling. For a pathological gambler, the preoccupation with and impulse to gamble intensifies when the individual is under stress. This is not the case with non-pathological gambling. Pathological gambling occurs more commonly among men not women and generally runs a chronic not acute course.

Cognitive Level: Analysis
Integrated Process: Assessment

19. A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed?
1. “The state board of nursing must be notified with factual documentation of impairment.”
2. “All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice.”
3. “Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work.”
4. “After a return to practice, a recovering nurse may be closely monitored for several years.”

ANS: 2
Rationale: Several state boards of nursing have passed diversionary laws that allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. This may require successful completion of inpatient, outpatient, group, or individual counseling treatment program(s); evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period. When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings.

Cognitive Level: Application
Integrated Process: Assessment

Multiple Response

20. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.)
1. “I am easily manipulated and need to work on this prior to caring for these clients.”
2. “Because of my father’s alcoholism, I need to examine my attitude toward these clients.”
3. “I need to review the side effects of the medications used in the withdrawal process.”
4. “I’ll need to set boundaries to maintain a therapeutic relationship.”
5. “I need to take charge when dealing with clients diagnosed with substance disorders.”

ANS: 1, 2, 4
Rationale: The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients diagnosed with this problem.

Cognitive Level: Application
Integrated Process: Implementation

21. A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.)
1. “A diet rich in protein will promote hepatic healing.”
2. “This condition results from a rise in serum ammonia, leading to impaired mental functioning.”
3. “In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity.”
4. “Neomycin and lactulose are used in the treatment of this condition.”
5. “This condition is caused by the inability of the liver to convert ammonia to urea.”

ANS: 1
Rationale: The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing. The treatment of hepatic encephalopathy requires abstention from alcohol and temporary elimination of protein from the diet.

Cognitive Level: Application
Integrated Process: Evaluation

22. A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.)
1. Stressful situations precipitate gambling behaviors.
2. Anxiety and restlessness can only be relieved by placing a bet.
3. Winning brings about feelings of sexual satisfaction.
4. Gambling is used as a coping strategy.
5. Losing at gambling meets the client’s need for self-punishment.

ANS: 1, 2, 4, 5
Rationale: In gambling disorder, the preoccupation with and impulse to gamble intensifies when the individual is under stress. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. Winning brings feelings of special status, power, and omnipotence, not sexual satisfaction. The gambler increasingly depends on this activity to cope with disappointments, problems, and negative emotional states.

Cognitive Level: Application
Integrated Process: Assessment

23. A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect that the staff nurse is impaired? (Select all that apply.)
1. The staff nurse is frequently absent from work.
2. The staff nurse experiences mood swings.
3. The staff nurse makes elaborate excuses for behavior.
4. The staff nurse frequently uses the restroom.
5. The staff nurse has a flushed face.

ANS: 2, 3, 4, 5
Rationale: A number of clues for recognizing substance impairment in nurses have been identified. They are not easy to detect and will vary according to the substance being used. There may be high absenteeism if the person’s source is outside the work area, or the individual may rarely miss work if the substance source is at work. Some other possible signs are irritability, mood swings, tendency to isolate, elaborate excuses for behavior, unkempt appearance, impaired motor coordination, slurred speech, flushed face, inconsistent job performance, and frequent use of the restroom.

Cognitive Level: Application
Integrated Process: Assessment

24. A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.)
1. A hotline number will be available in order to call for peer assistance.
2. A verbal contract detailing the method of treatment will be initiated prior to the program.
3. Peer support is provided through regular contact with the impaired nurse.
4. Contact to provide peer support will last for one year.
5. One of the program goals is to intervene early in order to reduce hazards to clients.

ANS: 1, 3, 5
Rationale: The peer assistance programs strive to intervene early, to reduce hazards to clients, and increase prospects for the nurse’s recovery. Most states provide either a hotline number that the impaired nurse may call or phone numbers of peer assistance committee members, which are made available for the same purpose. Typically, a written, not verbal, contract is drawn up, detailing the method of treatment, which may be obtained from various sources, such as employee assistance programs, Alcoholics Anonymous, Narcotics Anonymous, private counseling, or outpatient clinics. Peer support is provided through regular contact with the impaired nurse, usually for a period of two years, not one year.

Cognitive Level: Application
Integrated Process: Assessment

25. A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.)
1. The client has a long history of focusing thoughts and behaviors on other people.
2. The client, as a child, experienced overindulgent and overprotective parents.
3. The client is a people pleaser and does almost anything to gain approval.
4. The client exhibits helpless behaviors but actually feels very competent.
5. The client can achieve a sense of control only through fulfilling the needs of others.

ANS: 1, 3, 5
Rationale: The codependent person has a long history of focusing thoughts and behavior on other people and is able to achieve a sense of control only through fulfilling the needs of others. Codependant clients are “people pleasers” and will do almost anything to get the approval of others. They usually have experienced abuse or emotional neglect as a child. They outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all.

Cognitive Level: Application
Integrated Process: Assessment

Ordered Response

26. Order the following stages of the codependency recovery process according to Cermak.
________ The Core Issues Stage
________ The Reintegration Stage
________ The Survival Stage
________ The Reidentification Stage

ANS: The correct order is 3, 4, 1, 2
Rationale: Cermak in 1986 identified four stages in the recovery process for individuals with codependent personality: During the survival stage, the codependent must begin to let go of denial. During the reidentification stage, the individual begins to glimpse their true selves. During the core issues stage, the individual must face the fact that relationships cannot be managed by force or will. During the reintegration stage, control is achieved through self-discipline and self-confidence.
1. The Survival Stage
2. The Reidentification Stage
3. The Core Issues Stage
4. The Reintegration Stage

Cognitive Level: Analysis
Integrated Process: Assessment

Fill-in-the-Blank

27. The concept of _______________________ arose out of a need to define the dysfunctional behaviors that are evident among members of the family of a chemically dependent person.

ANS: codependency
Rationale: The concept of codependency arose out of a need to define the dysfunctional behaviors that are evident among members of the family of a chemically dependent person. The term has been expanded to include all individuals from families that harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions.

Cognitive Level: Application
Integrated Process: Assessment