Answer Options:
a. Jaundice
b. Dependent edema
c. Healthy but underweight
d. Facial abnormalities and growth retardation
Answer: d. Facial abnormalities and growth retardation
Question: A nurse overhears a nurse say, “I can handle the drinking. I just have to cut back. Work after attending to a relative’s needs is a strain. I need a few drinks at the local liquor store when a nurse visits.” Which nursing diagnosis applies?
Answer Options:
a. Ineffective coping
b. Denial
c. Defensive coping
d. Ineffective denial
Answer: b. Denial
Question: A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled “lorazepam.” What is the nurse’s first action?
Answer Options:
a. Test reflexes.
b. Check pupils.
c. Initiate vomiting.
d. Establish a patent airway.
Answer: d. Establish a patent airway.
Question: A nurse can assist a patient diagnosed with addiction and the patient’s family in which aspects of relapse prevention? (Select all that apply.)
Answer Options:
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
Answer: a. Rehearsing techniques to handle anticipated stressful situations
c. Assisting the patient to identify life skills needed for effective coping
e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances
Question: 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/min. 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?
Answer Options:
a. The patient is attempting to obtain attention by manipulating staff.
b. The patient may have sustained a head injury before admission.
c. The patient has symptoms of alcohol withdrawal delirium.
d. The patient is having a recurrence of an acute psychosis.
Answer: c. The patient has symptoms of alcohol withdrawal delirium.
Question: While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? (Select all that apply.)
Answer Options:
a. Administration of naloxone (Narcan)
b. Vitamin B12 and folate supplementation
c. Restraint of movements
d. Providing artificial respiration
e. Reduction of fever
Answer: a. Administration of naloxone (Narcan)
e. Reduction of fever
Question: A patient is admitted in a comatose state after ingesting five capsules of lorazepam. A friend of the patient says, “Often my friend drinks, along with taking more than is prescribed.” What is the effect of the use of alcohol with the lorazepam?
Answer Options:
a. The drug’s metabolism is stimulated.
b. The drug’s effect is diminished.
c. A synergistic effect occurs.
d. There is no effect.
Answer: c. A synergistic effect occurs.
Question: Which statement most accurately describes substance addiction?
Answer Options:
a. A chronic, relapsing brain disease associated with craving and a lack of control over use of a substance.
b. A disorder associated with tolerance to a substance as well as withdrawal symptoms if use is abruptly discontinued.
c. Behaviors associated with habitual use of a substance for the single purpose of altering one’s mood, emotion, or state of consciousness.
d. A behavioral disorder associated with selected personality features.
Answer: a. A chronic, relapsing brain disease associated with craving and a lack of control over use of a substance.
Question: 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. Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw?
Answer Options:
a. The patient rarely drinks alcohol.
b. The patient has a high tolerance to alcohol.
c. The patient has been treated with disulfiram.
d. The patient has recently ingested both alcohol and sedative drugs.
Answer: b. The patient has a high tolerance to alcohol.
Question: Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
Answer Options:
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?”
Answer: b. “When did you have your last drink?”
Question: Which treatment approach is most appropriate for a patient with poor social skills who has been treated several times for substance addiction but has relapsed?
Answer Options:
a. 1-week detoxification program
b. Long-term outpatient therapy
c. 12-step self-help program
d. Residential program
Answer: d. Residential program
Question: Select the nursing intervention necessary after administering naloxone to a patient experiencing an opiate overdose.
Answer Options:
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.
Answer: a. Monitor the airway and vital signs every 15 minutes.
Question: A patient tells the nurse, “My husband is abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me.” What risk factor was most predictive for the husband to become abusive?
Answer Options:
a. History of family violence
b. Loss of employment
c. Abuse of alcohol
d. Poverty
Answer: a. History of family violence
Question: A patient admitted for a heroin overdose received naloxone. The patient’s breathing pattern improved. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, “I feel terrible.” Which analysis is correct?
Answer Options:
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.
Answer: c. Symptoms of opiate withdrawal are present.
Question: Which scenario predicts the highest risk for directing violent behavior toward others?
Answer Options:
a. Major depressive disorder with delusions of worthlessness
b. Obsessive-compulsive disorder; performing ritualistic behavior
c. Schizophrenia; disorganized, fearful that food is being poisoned
d. Completion of alcohol withdrawal and beginning a recovery program
Answer: c. Schizophrenia; disorganized, fearful that food is being poisoned
Question: 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?
Answer Options:
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit.
Answer: c. Provide one-on-one supervision.
Question: A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
Answer Options:
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)
Answer: b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)