NURS 206 Mental Health 3 Questions and Answers,100% CORRECT

NURS 206 Mental Health 3 Questions and Answers Chapter 06: Legal and Ethical Basis for Practice 1. A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice. ANS: D Autonomy is the right to self-determination, that is, to make one’s own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice. 2. Which action by a psychiatric nurse best supports a patients right to be treated with dignity and respect? a. Consistently addressing a patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient’s condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning. ANS: A A simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patient’s condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity. 3. Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery. ANS: C Patients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patient’s autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery. 4. In a team meeting a nurse says, I’m concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision. Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice ANS: D The nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one’s own decisions. Fidelity is the observance of loyalty and commitment to the patient. 5. Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patients admission status is changed from involuntary to voluntary after the patients’ hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed. ANS: D A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts. 6. A nurses neighbor asks, why aren’t people with mental illness kept in state institutions anymore? What is the nurses best response? a. Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent. b. Less restrictive settings are now available to care for individuals with mental illness. c. Our nation has fewer persons with mental illness; therefore, fewer hospital beds are needed. d. Psychiatric institutions are no longer popular as a consequence of negative stories in the press. ANS: B The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness. 7. Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, I’m getting out of here and no one can stop me. The nurse restrains this patient without a health care providers order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, stay in your room or you’ll be put in seclusion. c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving. ANS: B False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distractor is not competent, and the nurse is acting beneficently. The patients in the other distractors have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team. 8. A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy. ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization. 9. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, Stop! I don’t want to take that medicine anymore. I hate the side effects. Select the nurse’s best initial action. a. Stop the medication administration procedure and say to the patient, tell me more about the side effects you’ve been having. b. Say to the patient, Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about skipping next month’s dose. c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary. ANS: A Patients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patient’s decision and should not force the medication. 10. Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted. ANS: A Nurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded. 11. A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient ANS: D Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient. 12. An example of a breach of a patients right to privacy occurs when a nurse: a. asks a family to share information about a patient’s prehospitalization behavior. b. discusses the patient’s history with other staff members during care planning. c. documents the patients’ daily behaviors during hospitalization. d. releases information to the patient’s employer without consent. ANS: D The release of information without patient authorization violates the patients right to privacy. The other options are acceptable nursing practices. 13. An adolescent hospitalized after a violent physical outburst tells the nurse, I’m going to kill my father, but you can’t tell anyone. Select the nurse’s best response. a. You’re right. Federal law requires me to keep that information private. b. Those kinds of thoughts will make your hospitalization longer. c. You really should share this thought with your psychiatrist. d. I am required to share information with the treatment team. ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for the nurse in this circumstance because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm. 14. A voluntarily hospitalized patient tells the nurse, get me the forms for discharge against medical advice so I can leave now. What are the nurses best initial response? a. I can’t give you those forms without your health care providers knowledge. b. I will get them for you, but let’s talk about your decision to leave treatment. c. Since you signed your consent for treatment, you may leave if you desire. d. I’ll get the forms for you right now and bring them to your room. ANS: B A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient’s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care providers knowledge is not true. Facilitating discharge without consent is not in the patient’s best interest before exploring the reason for the request. 15. The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will never get any treatment. Which reply by the nurse would be most helpful? a. Under the law, treatment must be provided. Hospitalization without treatment violates patient’s rights. b. That’s a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety. c. Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable. d. All patients in public hospitals have the right to choose both a primary therapist and a primary nurse. ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964. Stating that the concern is justifiable supports the family’s erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care. 16. Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse. ANS: C Throwing a heavy plate is likely to harm the waiter and is evidence of being dangerous to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. 17. A patient being treated in an alcohol rehabilitation unit reveals to the nurse, I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted. Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, I’m glad you feel comfortable talking to me about it. c. respect the nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead. ANS: A Laws regarding reporting child abuse discovered by a professional during a suspected abuser’s alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility. Anonymously reporting the abuse by telephone to the local child abuse hotline meets federal criteria. Respecting nurse-patient confidentiality and replying I’m glad you feel comfortable talking to me about it do not accomplish reporting. Filing a written report on agency letterhead violates federal law. 18. The spouse of a patient who has delusions asks the nurse, are there any circumstances under which the treatment team is justified in violating the patients right to confidentiality? The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person. ANS: D The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patients right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations. 19. A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider. ANS: D The dose of an antidepressant medication for older adult patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse’s duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dose is excessive. Implementing the order is negligent. Giving the usual geriatric dose would be wrong; a nurse without prescriptive privileges cannot change the dose. 20. A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient’s confidentiality. d. avoided charges of malpractice. ANS: B The duty of a health care professional is to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional and not considered a violation of confidentiality. 21. After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, please document the administration of the medication I forgot to do. My password is alpha1. The nurse should: a. fulfill the request. b. refers the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patients’ health care provider. ANS: B At most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patients’ health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem. 22. A patient diagnosed with mental illness asks a psychiatric technician, What’s the matter with me? The technician replies, your wing nuts need tightening. The nurse who overheard the exchange should take action based on: a. violation of the patients right to be treated with dignity and respect. b. the nurse’s obligation to report caregiver negligence. c. preventing defamation of the patient’s character. d. supervisory liability. ANS: A Patients have the right to be treated with dignity and respect. Patients should never be made the butt of jokes about their illness. Patient emotional abuse has been demonstrated, not negligence. The technician’s response was not clearly defamation. Patient abuse, not supervisory liability, is the issue. 23. Which documentation of a patient’s behavior best demonstrates a nurse’s observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, I need protection from dangerous bacteria trying to penetrate my skin. ANS: D The documentation states specific observations of the patient’s appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways. Select All That Apply 1. A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5) b. States nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric Mental Health Nursing ANS: C, E Regulations regarding hospitals provide information about the minimal standard. The American Nurses Association (ANA) national standards focus on elevating practice by setting high standards for nursing practice. The DSM-5 and the states nurse practice act would not provide relevant information. A summary of common practices of several local hospitals cannot be guaranteed to be helpful because the customs may or may not comply with laws or best practices. 2. In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians’ Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider. ANS: C, D Both instances jeopardize patient safety. The nurse must practice within the Code of Ethics for Nurses. A peer being unable to write behavioral outcomes is a concern but can be informally resolved. A health care provider consulting the Physicians’ Desk Reference is acceptable practice. 3. Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patients care because of concerns about countertransference. ANS: A, B Abandonment arises when a nurse does not place a patient safely in the hands of another health professional before discontinuing treatment. Calling the police to bring a suicidal patient to the hospital after a suicide attempt and referring a patient with schizophrenia to community treatment both provide for patient safety. Asking another nurse to provide a patients care because of concerns about countertransference demonstrates self-awareness. Chapter 18: Neurocognitive Disorders 1. An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer disease. ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. 2. A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, Bugs are crawling on my legs! Get them off! Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance ANS: C The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. 3. A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, someone get these bugs off me. What is the nurses best response? a. There are no bugs on your legs. Your imagination is playing tricks on you. b. Try to relax. The crawling sensation will go away sooner if you can relax. c. Don’t worry. I will have someone stay here and brush off the bugs for you. d. I don’t see any bugs, but I know you are frightened so I will stay with you. ANS: D When hallucinations are present, the nurse should acknowledge the patients’ feelings and state the nurse’s perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patients perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions. 4. What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs ANS: B The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient’s sensorium is clouded. The other diagnoses may be concerns but are lower priorities. 5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints ANS: C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury while hospitalized. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced. 6. Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? a. Keep the patient by the nurse’s desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation. ANS: D A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. 7. Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, I see scary faces. b. states, I feel bugs crawling on my legs and biting me. c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken. ANS: B Hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli. 8. Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia ANS: B The listed health problems are all forms of dementia. 9. When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne) ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer disease. 10. An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario. 11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors’ homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late) ANS: B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late), the ability to talk and walk are eventually lost, and stupor evolves. 12. Consider these problems: apolipoprotein E (apoE) malfunction, neurotic plaques, neurofibrillary tangles, granulovacuolar degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeficiency syndrome (AIDS)related dementia ANS: A The problems are all aspects of the pathophysiologic characteristics of Alzheimer disease. 13. A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain ANS: B Memory impairment is present and expected in stage 1 Alzheimer disease. Patients diagnosed with early Alzheimer disease often have difficulty remembering names, so socialization is minimized. Data are not present to support the other diagnoses. 14. A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patients sense of humor by telling jokes. ANS: A Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless. 15. Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, move along, you’re blocking the road. The other patient turns, shakes a fist, and shouts, I know what you’re up to; you’re trying to steal my car. What is the nurses best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, Walk along in the hall. This is not a traffic intersection. c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, please quiet down. We do not allow violence here. ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired. 16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patients’ glasses and hearing aids. d. Keep the room brightly lit at all times. ANS: C Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations. 17. A patient diagnosed with stage 2 Alzheimer disease calls the police saying, an intruder is in my home. Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality. b. aphasia. c. apraxia. d. agnosia. ANS: D Agnosia is the inability to recognize familiar objects, parts of one’s body, or one’s own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress. 18. During morning care, a nursing assistant asks a patient diagnosed with dementia, how was your night? The patient replies, it was lovely. I went out to dinner and a movie with my friend. Which term applies to the patient’s response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium ANS: B Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient’s response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario. 19. A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails. ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night. Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions. ANS: A The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient experiencing delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium. 21. An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items. ANS: A Patient with moderate Alzheimer disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality. 22. A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurses best reply? a. Your family member will never again be able to identify you. b. I think that is a question the health care provider should answer. c. One never knows. Consciousness fluctuates in persons with dementia. d. It is disappointing when someone you love no longer recognizes you. ANS: D Therapeutic communication techniques can assist family members to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two of the incorrect response’s close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia. 23. A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars. ANS: B Reorientation may seem like arguing to a patient experiencing cognitive deficits and increases the patient’s anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation. 24. What does the priority need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering ANS: C In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication. 25. Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication. ANS: C Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used. 26. A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality. ANS: A Risk for injury is the nurses priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes may not be realistic. Select All That Apply 1. A patient diagnosed with Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patients plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient’s name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval. ANS:A,B,E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient’s name and the name of the item maintains patient identity and dignity (and provides information if the patient has agnosia). When a patient resists, using distraction and trying again after a short interval are appropriate because patient moods are often labile; the patient may be willing to cooperate during a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Staff members are prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication. 2. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention d. Apathy e. Agnosia ANS:A,B,C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression. 3. A nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory ANS:A,B,D The memories of patients with Alzheimer disease continue to deteriorate. These patients demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (Hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia. Memory does not improve. Chapter 19: Substance-Related and Addictive Disorders 1. A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped) ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium. 2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired. ANS: D Fetal alcohol syndrome is the result of alcohols inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors. 3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Bucks traction and screams, somebody tied me up with ropes. The patient is experiencing a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon. ANS: A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping. 4. A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. I’ve got to get out of here. What is the most accurate assessment of the 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 a recurrence of an acute psychosis. ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis. 5. A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes 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 Clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses. 6. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine ANS: C This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patients’ symptoms. 7. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit. ANS: C This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patients’ feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority. 8. A patient with a history of daily alcohol abuse says, Drinking helps me cope with being a single parent. Which response by the nurse would help the individual conceptualize the drinking more objectively? a. Sooner or later, alcohol will kill you. Then what will happen to your children? b. I hear a lot of defensiveness in your voice. Do you really believe this? c. If you were coping so well, why were you hospitalized again? d. Tell me what happened the last time you drank. ANS: D The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient. 9. A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse’s best response? a. It is a self-help group with the goal of sobriety. b. It is a form of group therapy led by a psychiatrist. c. It is a group that learns about drinking from a group leader. d. It is a network that advocates strong punishment for drunk drivers. ANS: A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed. 10. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs. ANS: B A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient’s body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs. 11. A patient admitted to an alcoholism rehabilitation program says, I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening. The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial ANS: D Minimizing one’s drinking is a form of denial of alcoholism. The patient’s own description indicates that social drinking is not an accurate name for the behavior. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one’s own system. 12. A new patient in an alcoholism rehabilitation program says, I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening. Which response by the nurse will help the patient view the drinking more honestly? a. I see, and use interested silence. b. I think you may be drinking more than you report. c. Being a social drinker involves having a drink or two once or twice a week. d. You describe drinking steadily throughout the day and evening. Am I correct? ANS: D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment. 13. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, after discharge, I’m sure everything will be just fine. Which remark by the nurse will be most helpful to the spouse? a. It is good that you’re supportive of your spouse’s sobriety and want to help maintain it. b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. c. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection. d. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse’s behavior carefully. ANS: B During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information. 14. The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse. ANS: A Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective. 15. When working with a patient beginning treatment for alcohol abuse, what is the nurses most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses. 16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patients’ reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient; we cannot see you today because you’ve been drinking. ANS: D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary. 17. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops. ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change. 18. Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug. ANS: A Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped. 19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, I feel terrible. Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse. ANS: C The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome. 20. In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge. ANS: A Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care. 21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter. ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use. 22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse’s drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers. ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility. 23. A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management. ANS: A Enabling denies the seriousness of the patients problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate. 24. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program ANS: D Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies. 25. Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane ANS: B Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both. 26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patients requests. d. Observe for depression and suicidal ideation. ANS: D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice. 27. Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache ANS: C The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible. 28. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug ANS: B Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug. 29. Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse. 30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression. ANS: C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illnes