Chapter 06: Substance Use Assessment

Multiple Choice

1. A woman has come to the clinic to seek help with a substance-abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman?

a. Dilated pupils, pacing, and psychomotor agitation b. Dilated pupils, unsteady gait, and aggressiveness c. Pupil constriction, lethargy, apathy, and dysphoria d. Constricted pupils, euphoria, and decreased temperature

ANS: A

A cocaine user’s appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The person’s behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Psychosocial Integrity a. Hypertension b. Ventricular fibrillation c. Bradycardia d. Mitral valve prolapse

2. The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. Which assessment finding should the nurse expect?

ANS: A

Alcohol has many effects on the cardiovascular (CV) system. Studies show that consuming more than 1 or 2 drinks of alcohol a day is associated with hypertension. Ventricular fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol. Although alcohol has many effects on the cardiovascular (CV) system, it is not associated with ventricular fibrillation, bradycardia, or mitral valve prolapse.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity a. ≥ 2.1/day b. ≥ 4.2/day c. ≥ 8/week d. ≥ 15/week

3. The nurse is conducting a class on alcohol and the effects of alcohol on the body. What information about the number of standard drinks (each containing 14 grams of alcohol) associated with a 32% increase in breast cancer should the nurse include in the class?

ANS: A

Drinking ≥30 grams/day of alcohol (2.1 standard drinks) increases the rate of breast cancer by 32% compared to those with no alcohol intake. The mechanism in causing breast cancer is likely an increase in estrogen steroids, increasing the risk for hormone-sensitive tumors.

Drinking ≥ 15 drinks per week for men and ≥ 8 drinks per week for women increases the risks for chronic diseases such as hypertension; heart disease; stroke; breast, oral, esophageal, liver, and colorectal cancers; and mental illness. The number of drinks associated with a 32% risk for developing breast cancer is ≥ 2.1 drinks/day.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Physiological Integrity: Reduction of Risk Potential a. Heroin b. Marijuana c. Crack cocaine d. Hallucinogens

4. During a session on substance abuse, the nurse is reviewing statistics with the class. For people aged 12 years and older, which illicit substance was most commonly used?

ANS: B

In people age 12 years and older who reported using during the past month, marijuana (hashish) was the most commonly used illicit drug reported.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Psychosocial Integrity a. “You should limit your drinking to once or twice a week.” b. “It’s okay to have up to two glasses of wine a day.” c. “As long as you avoid getting drunk, you should be safe.” d. “No amount of alcohol has been determined to be safe during pregnancy.”

5. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, “How many drinks a day is safe for my baby?” What is the best response by the nurse?

ANS: D No amount of alcohol has been determined to be safe for pregnant women. The potential adverse effects of alcohol use on the fetus are well known; women who are pregnant should be screened for alcohol use, and abstinence should be recommended.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control a. “I may have one or two drinks a week.” b. “I usually have three or four drinks a week.” c. “I’ll have a glass or two of wine every now and then.” d. “I have eight to ten drinks a week, but I never get drunk.”

6. During an assessment, the nurse asks a female patient, “How many alcoholic drinks do you have a week?” Which answer by the patient would indicate at-risk drinking?

ANS: D

According to the Centers for Disease Control and Prevention, having eight or more drinks a week or four or more drinks per occasion is considered at-risk drinking for women. For women, having seven or more drinks a week or three or more drinks per occasion is considered at-risk drinking, according to the National Institute on Alcohol Abuse and Alcoholism.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. “Who are these friends?” b. “Is this a regular habit?” c. “Do your parents know about this?” d. “When was the last time you used marijuana?”

7. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, “Yes, I’ve used marijuana at parties with my friends.” What is the next question the nurse should ask?

ANS: D

If a patient admits to the use of illicit substances, then the nurse should ask, “When was the last time you used drugs?” and “How much did you take that time?” The other questions may be considered accusatory and are not conducive to gathering information. Asking the person who the friends are, if it’s a regular habit, and if the parents know about it can be considered accusatory and are not conducive to gathering necessary information. Instead, if a patient admits to the use of illicit substances, the nurse should ask, “When was the last time you used drugs?” and “How much did you take that time?”

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Record the results of the assessment, and notify the physician on call. b. State, “You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I’m willing to help you.” c. State, “It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter.” d. Give the patient information about a local rehabilitation clinic.

8. The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time?

ANS: B

If an assessment has determined that the patient has at-risk drinking behavior, then the nurse should give a short but clear statement of assistance and concern. Simply giving out a telephone number or referral to agencies may not be enough.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control a. Alcohol b. Heroin c. Cocaine d. Sedatives

9. A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thought he had influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?

ANS: B

Withdrawal symptoms of opiates, such as heroin, are similar to the clinical picture of influenza and include symptoms such as dilated pupils, lacrimation, runny nose, tachycardia, fever, restlessness, muscle and joint pains, and other symptoms. These symptoms are not consistent with withdrawal form alcohol, cocaine, or sedatives.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity a. A physiologic dependence on a substance. b. A person requires an increased amount of the substance to produce the same effect. c. A person requires daily use of the substance to function and is unable to stop using it. d. A person experiences a syndrome of physiologic symptoms if the substance is not used.

10. The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance?

ANS: B

The concept of tolerance to a substance indicates that the person requires an increased amount of the substance to produce the same effect. A physiologic dependence on a substance is dependence; requiring daily use of a substance to function and being unable to stop using it describes substance abuse; and experiencing a syndrome of physiologic symptoms if the substance is not used is withdrawal.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. TWEAK b. AUDIT c. SMAST-G d. CIWA-Ar

11. The nurse is admitting a patient with an addiction to alcohol to a treatment center. Which screening tool should the nurse use to assess for symptoms of alcohol withdrawal?

ANS: D

The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is a tool used to assess and objectively measure the symptoms of alcohol withdrawal. The tool is quantified to measure the progress of withdrawal. The TWEAK, AUDIT, and SMAST-G are tools that assess for alcohol use or problems, not withdrawal.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. “I crave alcohol but have successfully cut down on my alcohol consumption.” b. “I’ve been late to work a few times so now I limit myself to 2 drinks/day and stick to it.” c. “I usually stay out longer and drink more than I intended but I still make it into work on time.” d. “I have a strong urge to drink and I’ve tried to stop drinking several times but it doesn’t last long.’

12. The nurse is conducting an interview with an adult male patient. Which statement made by the patient indicates an alcohol use disorder?

ANS: D

Craving of having a strong desire or urge to use alcohol and having a persistent desire or unsuccessful efforts to cut down on alcohol consumption are two of the diagnostic criteria for an alcohol use disorder. The diagnostic criterion for an alcohol use disorder is the manifestation of at least two characteristics listed in Table 6.2. Although craving alcohol is a manifestation, the patient appears to be able to cut down on consumption. If he had several unsuccessful efforts to cut down or quit drinking, that would have been a manifestation of a drinking problem. Although failure to fulfill major role obligations at work (such as arriving on time), home, or school is a manifestation of a problem, the patient appears able to successfully limit drinks to 2/day which for a male is not an at-risk behavior. Although drinking larger amounts or over an extended period of time is a manifestation of an alcohol use disorder, the patient appears to be able to fulfill major role obligations such as getting to work on time.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity

Multiple Response

1. When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk for alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? (Select all that apply.)

a. Increased muscle mass b. Decreased blood pressure c. Increased cardiac output d. Decreased liver metabolism e. Decreased kidney functioning

ANS: D, E

Decreased function of both the liver and kidney can increase the bioavailability of alcohol in the blood for longer periods. Aging people experience decreased muscle mass (not increased), which also increases the alcohol concentration in the blood because the alcohol is distributed to less tissue over time. Blood pressure and cardiac output are not factors regarding bioavailability. It is a decrease in liver and kidney functioning that increases the bioavailability of alcohol in the blood for longer periods.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Bradycardia b. Coarse tremor of the hands c. Transient hallucinations d. Somnolence e. Sweating

2. A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? (Select all that apply.)

ANS: B, C, E

Symptoms of uncomplicated alcohol withdrawal start shortly after the cessation of drinking, peak at the second day, and improve by the fourth or fifth day. Symptoms include coarse tremors of the hands, tongue, and eyelids; anorexia; nausea and vomiting; autonomic hyperactivity (e.g., tachycardia, sweating, elevated blood pressure); and transient hallucinations, among other symptoms (see Table 6-7). Bradycardia and somnolence are not symptoms of alcohol withdrawal.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity a. Headaches b. Hunger c. Sleepiness d. Restlessness e. Nervousness f. Sweating

3. A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop “cold turkey.” He asks the nurse, “What symptoms can I expect if I do this?” Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? (Select all that apply.)

ANS: A, B, D, E

Symptoms of nicotine withdrawal include vasodilation, headaches, anger, irritability, frustration, anxiety, nervousness, awakening at night, difficulty concentrating, depression, hunger, impatience, and the desire to smoke. Sleepiness and sweating are not symptoms of nicotine withdrawal.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity