Varcarolis Chapter 22 Substance Related and Addictive Disorders Exam
Questions and Answers With Verified Solutions 2025
1. A patient diagnosed with alcoholism 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.
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/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 148/94 mm Hg and 96 beats/min
What is the nurse's priority action?
a. Force fluids.
b. Consult the health care provider.
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 medical
intervention. 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.
, 3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the
highest priority?
a. Cardiovascular
b. Respiratory
c. Neurologic
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. See
relationship to audience response question.
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/min. 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.
5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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
Questions and Answers With Verified Solutions 2025
1. A patient diagnosed with alcoholism 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.
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/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 148/94 mm Hg and 96 beats/min
What is the nurse's priority action?
a. Force fluids.
b. Consult the health care provider.
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 medical
intervention. 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.
, 3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the
highest priority?
a. Cardiovascular
b. Respiratory
c. Neurologic
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. See
relationship to audience response question.
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/min. 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.
5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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
