Chapter 22: Substance-Related and Addictive Disorders

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

Multiple Choice

1. A patient diagnosed with alcohol use disorder asks, “How will Alcoholics Anonymous (AA) help me?” Select the nurse’s best response.

a. “The goal of AA is for members to learn controlled drinking with the support of a higher power.” b. “An individual is supported by peers while striving for abstinence one day at a time.” c. “You must make a commitment to permanently abstain from alcohol and other drugs.” d. “You will be assigned a sponsor who will plan your treatment program.”

ANS: B

Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 22-48, 50, 51

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:

0200: 118/78 mm Hg and 72 beats/minute

0400: 126/80 mm Hg and 76 beats/minute

0600: 128/82 mm Hg and 72 beats/minute

0800: 132/88 mm Hg and 80 beats/minute

1000: 148/94 mm Hg and 96 beats/minute a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

What is the nurse’s priority action?

ANS: B

Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 22-31, 32, 38, 39 TOP: Nursing Process: Implementation

MSC: Client Needs: Physiological Integrity a. Cardiovascular b. Respiratory c. Neurological d. Hepatic

3. A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?

ANS: B

Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 22-21, 58 (Table 22-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

4. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” Select the most accurate assessment of this 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 an acute psychosis.

ANS: C

Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 22-31, 32, 72 (Table 22-6) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

5. A patient admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?

ANS: D

The patient’s clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)