Question 1

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?

Accepted Answer

A) Darken the room to reduce stimuli in order to prevent seizures. 
B) Assess aggressive behaviors in order to intervene to prevent injury to self or others. 
C) Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. 
D) Teach the negative effects of alcohol on the body. 
A) Darken the room to reduce stimuli in order to prevent seizures. 
B) Assess aggressive behaviors in order to intervene to prevent injury to self or others. 
C) Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. 
D) Teach the negative effects of alcohol on the body.

Question 2

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

Accepted Answer

A) By asking directly if the client has ever had a problem with alcohol 
B) By holistically assessing the client using the CIWA scale 
C) By using a screening tool such as the CAGE questionnaire 
D) By referring the client for physician evaluation 
A) By asking directly if the client has ever had a problem with alcohol 
B) By holistically assessing the client using the CIWA scale 
C) By using a screening tool such as the CAGE questionnaire 
D) By referring the client for physician evaluation

Question 3

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement?

Accepted Answer

A) The client is using minimization as an ego defense. 
B) The client is ready to sign an Alcoholics Anonymous contract for sobriety. 
C) The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. 
D) The client has met the requirements to be designated as an Alcoholics Anonymous sponsor. 
A) The client is using minimization as an ego defense. 
B) The client is ready to sign an Alcoholics Anonymous contract for sobriety. 
C) The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. 
D) The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

Question 4

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?

Accepted Answer

A) "Why do you assume responsibility for his behaviors?" 
B) "Codependency is a typical behavior of spouses of alcoholics." 
C) "Your husband needs to deal with the consequences of his drinking." 
D) "Do you understand what the term 'enabler' means?" 
A) "Why do you assume responsibility for his behaviors?" 
B) "Codependency is a typical behavior of spouses of alcoholics." 
C) "Your husband needs to deal with the consequences of his drinking." 
D) "Do you understand what the term 'enabler' means?"

Question 5

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication?

Accepted Answer

A) "Only oral ingestion of alcohol will cause a reaction when taking this drug." 
B) "It is safe to drink beverages that have only 12% alcohol content." 
C) "This medication will decrease your cravings for alcohol." 
D) "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug." 
A) "Only oral ingestion of alcohol will cause a reaction when taking this drug." 
B) "It is safe to drink beverages that have only 12% alcohol content." 
C) "This medication will decrease your cravings for alcohol." 
D) "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

Question 6

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 dependence?

Accepted Answer

A) Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. 
B) Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. 
C) There is no need to assess the client for substance dependence.There is an obvious PCA malfunction. 
D) The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage. 
A) Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. 
B) Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. 
C) There is no need to assess the client for substance dependence.There is an obvious PCA malfunction. 
D) The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

Question 7

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

Accepted Answer

A) To assess for emotional strength 
B) To assess for Wernicke-Korsakoff syndrome 
C) To assess for tachycardia 
D) To assess for fine tremors 
A) To assess for emotional strength 
B) To assess for Wernicke-Korsakoff syndrome 
C) To assess for tachycardia 
D) To assess for fine tremors

Question 8

During group therapy, a client diagnosed with chronic alcohol dependence 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 a nurse interpret this statement?

Accepted Answer

A) The client is using denial by avoiding responsibility. 
B) The client is using displacement by blaming his wife. 
C) The client is using rationalization to excuse his alcohol dependence. 
D) The client is using reaction formation by appealing to the group for sympathy. 
A) The client is using denial by avoiding responsibility. 
B) The client is using displacement by blaming his wife. 
C) The client is using rationalization to excuse his alcohol dependence. 
D) The client is using reaction formation by appealing to the group for sympathy.

Question 9

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.)

Accepted Answer

A) "I am easily manipulated and need to work on this prior to caring for these clients." 
B) "Because of my father's alcoholism, I need to examine my attitude toward these clients." 
C) "I need to review the side effects of the medications used in the withdrawal process." 
D) "I'll need to set boundaries to maintain a therapeutic relationship." 
E) "I need to take charge when dealing with clients diagnosed with substance disorders." 
A) "I am easily manipulated and need to work on this prior to caring for these clients." 
B) "Because of my father's alcoholism, I need to examine my attitude toward these clients." 
C) "I need to review the side effects of the medications used in the withdrawal process." 
D) "I'll need to set boundaries to maintain a therapeutic relationship." 
E) "I need to take charge when dealing with clients diagnosed with substance disorders."

Question 10

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation?

Accepted Answer

A) The individual is experiencing psychological dependency. 
B) The individual is experiencing physical dependency. 
C) The individual is experiencing substance dependency. 
D) The individual is experiencing social dependency. 
A) The individual is experiencing psychological dependency. 
B) The individual is experiencing physical dependency. 
C) The individual is experiencing substance dependency. 
D) The individual is experiencing social dependency.

Exam 25: Substance-Related Disorders

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement?

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?

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication?

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 dependence?

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

During group therapy, a client diagnosed with chronic alcohol dependence 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 a nurse interpret this statement?

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.)

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation?

The Concept of Stress Adaptation

Mental Healthmental Illness: Historical and Theoretical Concepts

Theoretical Models of Personality Development

Concepts of Psychobiology

Ethical and Legal Issues in Psychiatricmental Health Nursing

Cultural and Spiritual Concepts Relevant to Psychiatricmental Health Nursing

Relationship Development

Therapeutic Communication

The Nursing Process in Psychiatricmental Health Nursing

Therapeutic Groups

Intervention With Families

Milieu Therapy - the Therapeutic Community

Crisis Intervention

Relaxation Therapy

Assertiveness Training

Promoting Self Esteem

Angeraggression Management

Intervention With a Suicidal Client

Behavior Therapy

Cognitive Therapy

Electroconvolusive Therapy

Complementary Therapies

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Delirium, Dementia, and Amnestic Disorders

Schizophrenia and Other Psychotic Disorders

Mood Diorders: Depression

Mood Disorders: Bipolar Disorder

Anxiety Disorders

Somatoform and Disassociative Disorders

Issues Related to Human Sexuality and Gender Identity

Eating Disorders

Adjustment and Impulse Control Disorders

Personality Disorders

The Aging Individual

Victims of Abuse or Neglect

Community Mental Health Nursing

Forensic Nursing

The Bereaved Individual

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