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Psychiatric Mental Health Nursing Chapter 25
Exam Latest Update
Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan for the client who is in withdrawal must include which nursing interventions? A: Vital signs and medications as prescribed B: Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered C: Suicide precautions because suicide attempts are frequent during withdrawal D: Seizure precautions and vital signs - answer B Nursing care of the client experiencing withdrawal centers on safety first. The nurse must implement frequent vital sign assessment, seizure precautions, and fall precautions to ensure the client's safety. Withdrawal symptoms must be controlled with medications. Which statement most accurately describes the etiology of substance-related disorders? A: Substance-related disorders result from the interplay of biologic, genetic, and psychosocial factors. B: Substance-related disorders are primarily a result of the presence of an individual's inherently addictive personality. C: The primary predictors of substance-related disorders are childhood trauma and parental abuse or neglect. D: Substance abuse is a learned behavior - answer A Rationale: Substance-related disorders have a complex etiology, and contributions have been noted from a combination of neurological, genetic, behavioral, and sociocultural sources. The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse that his relationship with the client was codependent and enabling. Which of the following is an example of codependent behavior?
A: The friend called Alcoholics Anonymous when the client expressed a need to stop drinking. B:The friend called the client every night to make sure he got home safely, and went looking for him if he was not at home. C: The friend confronted the client on the effect of his drinking on their relationship. D: The friend refused to go out drinking with the client to celebrate the client's birthday. - answer B Rationale: Codependent behavior appears helpful on the surface but actually prolongs the drinking behavior. Answers A, C, and D are not examples of codependent behavior. Disulfiram should not be administered until a client has abstained from alcohol for at least how long? A: 12 hours B: 4 hours C: 8 hours D: 16 hours - answer A Rationale: Warnings related to disulfiram include never administering the drug to an intoxicated client or without the client's knowledge, and not administering the drug until the client has abstained from alcohol for at least 12 hours. Which characteristic of the 12-step program distinguishes it from other programs? A: The philosophy that it is possible to reduce the use of substances without abstaining. B: It is a self-help group that focuses on total abstinence. C: Persons who use this program are independent in their sobriety. D: Infrequent attendance is usually successful. - answer B Rationale: Alcoholics Anonymous was founded in the 1930s by alcoholics. This self-help group developed the 12-step program model for recovery, which is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. Regular attendance at meetings is emphasized.
local community group. When describing the incidence, which age group would the nurse identify as experiencing an increase? A: Adolescents B: Chronically ill females C: Cognitively impaired older adults D: Middle-age males - answer A: Adolescents Rationale: Alcohol, tobacco, marijuana, and illegal prescription drug use have reached epidemic proportions in the United States, with the incidence rising in younger age groups, particularly among adolescents and young adults. A client with opioid addiction is prescribed methadone maintenance therapy. When explaining this treatment to the client, which of the following would the nurse need to keep in mind? A: Methadone is a not physiologically addictive. B: The drug helps to satisfy the craving for the opioid. C: Methadone is a non-opioid drug. D: Methadone simulates the high of heroin. - answer B: The drug helps to satisfy the craving for the opioid. Rationale: Methadone maintenance is the treatment of people with opioid addiction with a daily, stabilized dose of methadone. Methadone is used because of its long half-life of 15 to 30 hours. Methadone is a potent opioid and is physiologically addicting, but it satisfies the opioid craving without producing the subjective high of heroin. An intoxicated client was admitted for trauma treatment last night at 2:00 AM (0200). When should the nurse expect to be alert for withdrawal symptoms?
A: between 8:00 and 10:00 AM (0800 and 1000) today (6 to 8 hours after drinking stopped) B: about 2:00 AM (0200) tomorrow (24 hours after drinking stopped) C: about 2:00 AM (0200) of hospital day 2 (48 hours after drinking stopped) D: about 2:00 AM (0200) of hospital day 3 (72 hours after drinking stopped - answer A: between 8:00 and 10:00 AM (0800 and 1000) today (6 to 8 hours after drinking stopped) Rationale: Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (called delirium tremens (DTs)). Alcohol withdrawal usually peaks on the second day and is over in about 5 days Safe alcohol withdrawal usually is accomplished with the administration of which medication classification? A: Benzodiazepines B: Antipsychotics C: Antidepressants D: Anticonvulsants - answer A: Benzodiazepines Rationale: Benzodiazepines are used for safe withdrawal of alcohol. Disulfiram has been prescribed for a client receiving treatment for alcoholism. Which should be included in the client's plan of care? A: Avoid all products containing alcohol B: Do not drive heavy machinery C: Have weekly blood alcohol levels drawn
D: Anhidrosis, hypotonicity, and delusions - answer A: Tremors, headache, flushed face, and hallucinations Rationale: Symptoms of alcohol withdrawal include tremors, headache, flushed face, and hallucinations. The client will experience hypertension (not hypotension), tachycardia (not bradycardia), and diaphoresis (not anhidrosis). A nurse is working in an intensive care unit and observes that some clients do not respond to injections of diazepam (Valium) when the injections are given by another nurse. That nurse returns from lunch exhibiting slurred speech and euphoria. Which of the following is the best action for the ICU nurse to take? A: Ask other nurses if they have noticed anything unusual. B: Call the manager and report the observations. C: Observe the nurse as injections are prepared and administered. D: Tell the nurse, "I know you've been stealing Valium." - answer B: Call the manager and report the observations. Rationale: Any suspicions should be communicated to someone in a supervisory position so that effective action can be taken. A client is being discharged from an alcoholism treatment center. Which of the following is a realistic client statement? A: "I'm going to take it one day at a time." B: "I will never use alcohol again." C: "I have to limit my alcohol use." D: "When I have met by sobriety goal, I will have one drink to celebrate." - answer A: "I'm going to take it one day at a time."
Rationale: Twelve-step programs focus on recovery "one day at a time." Total abstinence is essential to the 12-step process. Which is an example of a benzodiazepine? A: Diazepam B: Naltrexone C: Haloperidol D: Disulfiram - answer A: Diazepam Rationale: Diazepam is classified as a benzodiazepine, one of the most commonly used medications. Naltrexone is a narcotic antagonist used in the treatment of alcohol or narcotic dependence. Haloperidol is an antipsychotic drug used in the treatment of hallucinations. Disulfiram is used in the treatment of alcohol abuse. A client drinks 24 oz. of vodka every day, having gradually increased to this level over the past 2 to 3 years. The client continues to maintain a job and functions well in activities of daily living, relationships, and other aspects of social life. Which term should the nurse use to describe this drinking behavior? A: Abuse B: Tolerance C: Withdrawal D: Intoxication - answer B: Tolerance Rationale: Tolerance is characterized by a need for more of a substance to achieve the same effects from it. Abuse describes maladaptive behaviors related to alcohol or other substances. Withdrawal is a set of symptoms that occur when a client is not ingesting a
attention from one thing to another. It disrupts coordination of movement, balance, and reaction time. Contrary to popular belief, marijuana is addictive, is an irritant to the lungs, and can produce the same respiratory problems experienced by tobacco users (daily cough, phlegm). People who smoke marijuana miss work more than those who do not smoke, but it is not yet known whether marijuana smoke contributes to the risk of lung cancer. A client has been using paint thinner and glue to receive a "high." The nurse knows that these are what type of substances? A: inhalants. B: hallucinogens. C: sedatives. D: hypnotics. - answer A: inhalants. Explanation: Inhalants include paint thinner, glue, gasoline, and spray paint. The nurse is performing a history and physical examination on a client with chronic alcoholism. The client has a history of gastritis, esophagitis, elevated liver enzymes, cardiomyopathy, and pancreatitis. Which of these conditions are attributable to the client's history of alcohol abuse? A: Pancreatitis and elevated liver enzymes B: Gastritis and elevated liver enzymes C: Pancreatitis, esophagitis, gastritis, and elevated liver enzymes D: All the conditions are attributable to the alcohol abuse - answer D: All the conditions are attributable to the alcohol abuse Explanation: Various medical conditions may alert the nurse to the early recognition of alcohol abuse problems, including gastritis or gastric ulcers, pancreatitis, esophagitis, mild
to moderate hypertension, cardiomyopathy, arrhythmias, alcoholic hepatitis, cirrhosis of the liver, decreased white blood cell production, decreased granulocyte adherence, and thrombocytopenia, or cancers of the mouth, pharynx, larynx, esophagus, pancreas, stomach, and colon. When discussing methadone treatment with a client, the nurse should include what? A: It decreases the severity of heroin withdrawal symptoms. B: The cure rate is extremely high. C: It takes 1 to 2 years to cure an opiate addict. D: It is a nonaddictive treatment. - answer A: It decreases the severity of heroin withdrawal symptoms. Explanation: Methadone is a substitute for heroin, reducing the severity of heroin withdrawal symptoms. It does not cure heroin addiction, and it is an addictive drug. Which factor would contraindicate the use of disulfiram in the treatment of a client who has an alcohol use disorder? A: The client has a demonstrated family history of alcoholism. B: The client engages in binge drinking a few times a week rather than drinking consistently each day. C: The client uses marijuana in addition to alcohol. D: The client had six drinks a few hours ago. - answer D: The client had six drinks a few hours ago. Explanation: Disulfiram may not be administered to a client who is acutely intoxicated. A family history of alcoholism, marijuana use, and binge drinking do not preclude the use of the drug.
D: Withdrawal - answer A: Addiction Explanation: Addiction is a condition of continued use of substances (or reward-seeking behaviors) despite adverse consequences. Use involves the ingestion, smoking, sniffing, or injection of some mind-altering substances. Abuse occurs when a person uses alcohol or drugs for the purpose of intoxication or, in the case of prescription drugs, for purposes beyond their intended use. Withdrawal refers to the period after which a person stops using or abusing substances; during this period the person may experience signs and symptoms due to the lack of the substance. Which medication is used to prevent alcohol withdrawal symptoms? A: Lorazepam (Ativan) B: Clonidine (Catapres) C: Folic acid (Folate) D: Naltrexone (ReVia) - answer A: Lorazepam (Ativan) Explanation: Safe withdrawal usually is accomplished with the administration of benzodiazepines, such as lorazepam, chlordiazepoxide, or diazepam, to suppress the withdrawal symptoms. Which of the following symptoms is consistent with alcohol withdrawal? A: Decreased blood pressure B: Dry skin C: Decreased heart rate D: Coarse hand tremors - answer D: Coarse hand tremors Explanation: Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction
of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, and insomnia. Wernick-Korsakoff syndrome is a neurologic condition that can result from heavy drinking. Which of the following medications is used to prevent Wernicke-Korsakoff syndrome? A: Folic acid (Folate) B: Thiamine (vitamin B1) C: Cyanocabalamin (vitamin B12) D: Lorazepam (Ativan) - answer B: Thiamine (vitamin B1) Explanation: Thiamine is used to prevent Wernicke-Korsakoff syndrome. Folic acid, vitamin B12, and lorazepam are not used for this disease process. A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client? A: Check the client's belongings for additional drugs. B: Pad the side rails of the bed because seizures are likely. C: Prepare a dose of ipecac, an emetic. D: Monitor respiratory function. - answer D: Monitor respiratory function. Explanation: Barbiturates are potent central nervous system depressants and can greatly decrease respiratory functioning. Respiratory depression would be a more likely and life- threatening complication than seizures, and would consequently be prioritized. Locating additional drugs does nothing to address life-threatening complications. Inducing vomiting would not remove drugs that the client has already metabolized, so would be of
used to promote a regular sleep pattern. Antipsychotic medications are also used if needed.
