molloy college:Chapter 22: Substance-Related and Addictive Disorders Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

. 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 ...

. 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 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 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 What is the nurse‘s priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint. 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 testbanks_and_xanax 3. A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurological d. Hepatic 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 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? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury 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. testbanks_and_xanax PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 22-31, 32 | Pages 22-39, 69 (Table 22-5) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment 6. A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine. ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 22-31, 32, 72 (Table 22-6) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity 7. A hospitalized patient diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids ANS: B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient‘s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 22-32, 39, 40, 69 (Table 22-5) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environmen