Chapter 23. Substance-Related and Addictive Disorders
Multiple Choice
1. What should be the priority nursing diagnosis for a client experiencing alcohol
withdrawal? A. Risk for injury R/T central nervous system stimulation
B. Disturbed thought processes R/T tactile hallucinations
C. Ineffective coping R/T powerlessness over alcohol use
D. Ineffective denial R/T continued alcohol use despite negative consequences
ANS: A
The priority nursing diagnosis for a client experiencing alcohol withdrawal should be
risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include
the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea
or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure;
anxiety; depressed mood; hallucinations; headache; and insomnia.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis |
Client Need:
Physiological Integrity: Reduction of Risk Potential
2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices
100 attempts within a 30- minute period. Which is the best rationale for assessing this
client for substance use disorder?
A. Narcotic pain medication is contraindicated for all clients with active substance-use
problems.
,B. Clients who are regularly using alcohol or benzodiazepines may have developed
cross-tolerance to analgesics and require increased doses to achieve effective pain
control.
C. There is no need to assess the client for substance use disorder. There is an
obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and
needs to be accurately assessed for lorazepam
(Ativan) dosage.
ANS: B
The nurse should assess the client for substance use disorder because clients who are
regularly using alcohol or benzodiazepines may have developed cross-tolerance to
analgesics and require increased doses to achieve effective pain control. Cross-
tolerance occurs when one drug lessens the clients response to another drug.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process:
Assessment | Client Need:
Physiological Integrity
3. On the first day of a clients alcohol detoxification, which nursing intervention should
take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous
meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D.
Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
ANS: C
The priority nursing intervention for this client should be to administer ordered
chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide
(Librium) is a benzodiazepine and is often used for substitution therapy in alcohol
, withdrawal. Substitution therapy may be required to reduce life-threatening effects of
the rebound stimulation of the central nervous system that occurs during withdrawal.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
4. Which client statement indicates a knowledge deficit related to substance use?
A. Although its legal, alcohol is one of the most widely abused drugs in our society. B.
Tolerance to heroin develops quickly.
C. Flashbacks from LSD use may reoccur spontaneously.
D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.
ANS: D
The nurse should determine that the client has a knowledge deficit related to
substance use when the client compares marijuana to smoking cigarettes and claims
it to be harmless. Both of these substances have potentially harmful effects. Cannabis
is the second most widely abused drug in the United States.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process:
Assessment | Client Need:
Health Promotion and Maintenance
5. A lonely, depressed divorce has been self-medicating with cocaine for the past year.
Which term should a nurse use to best describe this individuals situation?
Multiple Choice
1. What should be the priority nursing diagnosis for a client experiencing alcohol
withdrawal? A. Risk for injury R/T central nervous system stimulation
B. Disturbed thought processes R/T tactile hallucinations
C. Ineffective coping R/T powerlessness over alcohol use
D. Ineffective denial R/T continued alcohol use despite negative consequences
ANS: A
The priority nursing diagnosis for a client experiencing alcohol withdrawal should be
risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include
the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea
or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure;
anxiety; depressed mood; hallucinations; headache; and insomnia.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis |
Client Need:
Physiological Integrity: Reduction of Risk Potential
2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices
100 attempts within a 30- minute period. Which is the best rationale for assessing this
client for substance use disorder?
A. Narcotic pain medication is contraindicated for all clients with active substance-use
problems.
,B. Clients who are regularly using alcohol or benzodiazepines may have developed
cross-tolerance to analgesics and require increased doses to achieve effective pain
control.
C. There is no need to assess the client for substance use disorder. There is an
obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and
needs to be accurately assessed for lorazepam
(Ativan) dosage.
ANS: B
The nurse should assess the client for substance use disorder because clients who are
regularly using alcohol or benzodiazepines may have developed cross-tolerance to
analgesics and require increased doses to achieve effective pain control. Cross-
tolerance occurs when one drug lessens the clients response to another drug.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process:
Assessment | Client Need:
Physiological Integrity
3. On the first day of a clients alcohol detoxification, which nursing intervention should
take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous
meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D.
Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
ANS: C
The priority nursing intervention for this client should be to administer ordered
chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide
(Librium) is a benzodiazepine and is often used for substitution therapy in alcohol
, withdrawal. Substitution therapy may be required to reduce life-threatening effects of
the rebound stimulation of the central nervous system that occurs during withdrawal.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
4. Which client statement indicates a knowledge deficit related to substance use?
A. Although its legal, alcohol is one of the most widely abused drugs in our society. B.
Tolerance to heroin develops quickly.
C. Flashbacks from LSD use may reoccur spontaneously.
D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.
ANS: D
The nurse should determine that the client has a knowledge deficit related to
substance use when the client compares marijuana to smoking cigarettes and claims
it to be harmless. Both of these substances have potentially harmful effects. Cannabis
is the second most widely abused drug in the United States.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process:
Assessment | Client Need:
Health Promotion and Maintenance
5. A lonely, depressed divorce has been self-medicating with cocaine for the past year.
Which term should a nurse use to best describe this individuals situation?
