Question 1

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?

Accepted Answer

A)  Antagonist therapy
B)  Deterrent therapy
C)  Codependency therapy
D)  Substitution therapy D

Question 2

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?

Accepted Answer

A)  50 mg/dL
B)  100 mg/dL
C)  250 mg/dL
D)  300 mg/dL B

Question 3

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 24 hours. Which client symptom should the nurse immediate report to the ED physician?

Accepted Answer

A)  Tactile hallucinations
B)  Blood pressure of 180/100 mm Hg
C)  Mood rating of 2/10 on numeric scale
D)  Dehydration B

Question 4

On the first day of a client's alcohol detoxification, which nursing intervention should take priority?

Accepted Answer

A)  Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B)  Educate the client about the biopsychosocial consequences of alcohol abuse.
C)  Administer ordered chlordiazepoxide (Librium)  in a dosage according to protocol.
D)  Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

Question 5

Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F1F1F1S1?F1F1F10F (36F1F1F1S1?F1F1F10C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?

Accepted Answer

A)  Knowledge deficit
B)  Fluid volume excess
C)  Imbalanced nutrition: less than body requirements
D)  Ineffective individual coping

Question 6

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

Accepted Answer

A)  The client will identify one person to turn to for support.
B)  The client will give up all old drinking buddies.
C)  The client will be able to verbalize the effects of alcohol on the body.
D)  The client will correlate life problems with alcohol use.

Question 7

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.)

Accepted Answer

A)  "A diet rich in protein will promote hepatic healing."
B)  "This condition leads to a rise in serum ammonia resulting in impaired mental functioning."
C)  "In this condition, blood accumulates in the abdominal cavity."
D)  "Neomycin and lactulose are used in the treatment of this condition."
E)  "This condition is caused by the inability of the liver to convert ammonia to urea."

Question 8

Which client statement demonstrates positive progress toward recovery from substance abuse?

Accepted Answer

A)  "I have completed detox and therefore am in control of my drug use."
B)  "I will faithfully attend Narcotic Anonymous (N
A)   when I can't control my carvings."
C)  "As a church deacon, my focus will now be on spiritual renewal."
D)  "Taking those pills got out of control.It cost me my job, marriage, and children."

Question 9

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

Accepted Answer

A)  Risk for injury R/T central nervous system stimulation
B)  Disturbed thought processes R/T tactile hallucinations
C)  Ineffective coping R/T powerlessness over alcohol use
D)  Ineffective denial R/T continued alcohol use despite negative consequences

Question 10

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem?

Accepted Answer

A)  Ineffective coping R/T unresolved anxiety AEB substance abuse
B)  Anxiety R/T poor sleep AEB difficulty falling asleep
C)  Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
D)  Risk for injury R/T addiction to Librium

Question 11

Which client statement indicates a knowledge deficit related to substance abuse?

Accepted Answer

A)  "Although it's legal, alcohol is one of the most widely abused drugs in our society."
B)  "Tolerance to heroin develops quickly."
C)  "Flashbacks from LSD use may reoccur spontaneously."
D)  "Marijuana is like smoking cigarettes.Everyone does it.It's essentially harmless."

Question 12

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms?

Accepted Answer

A)  Between 3 a.m.and 11 a.m.
B)  Shortly after a 24-hour period
C)  At the beginning of the third day
D)  Withdrawal is individualized and cannot be predicted.

Question 13

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?

Accepted Answer

A)  "I'm not going to use heroin ever again.I know I've got the willpower to do it this time."
B)  "I cannot control my use of heroin.It's stronger than I am."
C)  "I'm going to get all my children back.They need their mother."
D)  "Once I deal with my childhood physical abuse, recovery should be easy."

Question 14

In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention?

Accepted Answer

A)  Dextroamphetamine (Dexedrine) 
B)  Diazepam (Valium) 
C)  Morphine (Astramorph) 
D)  Phencyclidine (PCP)

Question 15

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching?

Accepted Answer

A)  After discharge, the client will immediately attend 90 AA meetings in 90 days.
B)  After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C)  After discharge, the client will incorporate family in AA attendance.
D)  After discharge, the client will seek appropriate deterrent medications through AA.

Question 16

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse?

Accepted Answer

A)  "This medication will help you maintain your abstinence."
B)  "This medication will cause uncomfortable symptoms if you combine it with alcohol."
C)  "This medication will decrease the effect alcohol has on your body."
D)  "This medication will lower your risk of experiencing a complicated withdrawal."

Question 17

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess?

Accepted Answer

A)  Gross tremors, delirium, hyperactivity, and hypertension
B)  Disorientation, peripheral neuropathy, and hypotension
C)  Oculogyric crisis, amnesia, ataxia, and hypertension
D)  Hallucinations, fine tremors, confabulation, and orthostatic hypotension

Question 18

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse?

Accepted Answer

A)  Alcohol poisoning
B)  Cardiovascular accident (CV
A)  
C)  A reaction to disulfiram (Antabuse) 
D)  A reaction to tannins in the red wine

Question 19

A client diagnosed with depression and substance abuse 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?

Accepted Answer

A)  Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
B)  Sedative-hypnotics are expensive and have numerous side effects.
C)  Sedative-hypnotics interfere with necessary REM (rapid eye movement)  sleep.
D)  Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

Question 20

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?

Accepted Answer

A)  Haloperidol (Haldol)  and fluoxetine (Prozac) 
B)  Carbamazepine (Tegretol)  and donepezil (Aricept) 
C)  Disulfiram (Antabuse)  and lorazepan (Ativan) 
D)  Chlordiazepoxide (Librium)  and phenytoin (Dilantin)

Exam 25: Substance-Related Disorders