Chapter 31: Substance Use Disorders
Steele: Keltner’s Psychiatric Nursing,
MULTIPLE CHOICE
1. The nurse suspect that a patient has developed a tolerance for alcohol. Which patient statement
supports that suspicion?
a. ―I felt good from drinking a six-pack a few months ago. Now I need a few extra
cans to get the same high.‖
b. ―I can stop drinking; I‘ve done it several times before.‖ c. ―I drink when I play cards with
the gang on weekends.‖ d. ―I‘ve been drinking most of adult life; I can handle it,‖.
ANS: A
Tolerance refers to the need for increasing amounts of a substance to achieve the same effects.
The other terms are not related to needing more of a substance to achieve the same effect.
DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment
, MSC: Client Needs: Psychosocial Integrity
2. Which statement made by the nurse best describes the experience of a patient who abuses
alcohol?
a. ―You can expect a comatose period related to alcohol withdrawal.‖
b. ―Alcohol intoxication and poisoning cause this state.‖
c. ―This is a time period in which a person who has used alcohol is unresponsive to
the environment.‖
d. This is an episode in which a person under the influence of alcohol functions
normally but later is unable to remember their actions.‖
ANS: D
A blackout is defined as a period of time in which a drinker functions socially but for which
there is no memory. The distracters omit aspects of a blackout.
DIF: Cognitive level: Evaluating TOP: Nursing process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. A patient diagnosed with Wernicke-Korsakoff syndrome has the nursing diagnosis impaired
memory, related to neurotoxicity of alcohol. Which statement made by the patient confirms the
presences of a defining characteristic that applies to this diagnosis?
a. ―I sometimes make up a story to cover up for something I can‘t remember.‖
b. ―I often hear voices that others claim they don‘t hear.‖
c. ―All of a sudden, I‘ll have a vivid memory of the accident that killed my son.‖
d. ―Regardless of what you say, I know that the mob or CIA is out to kill me.‖
ANS: A
Wernicke-Korsakoff syndrome is a mental disorder characterized by amnesia, clouding of
consciousness, confabulation (falsification of memory) and memory loss, and peripheral
neuropathy. Confabulation is a symptom typically displayed by an individual with Wernicke-
Korsakoff syndrome. The individual attempts to make up for memory loss by filling in the
, blanks with false memories. Auditory hallucinations are often described as hearing voices that no
one else can hear. Paranoid delusions are characterized by an
unrealistic or unsubstantiated belief that one is in danger. None of these options are symptoms of
memory impairment associated with Wernicke-Korsakoff syndrome.
DIF: Cognitive level: Analyzing TOP: Nursing process: Evaluation
MSC: Client Needs: Psychosocial Integrity
4. Which assessment findings would prompt the nurse to suspect a disulfiram reaction?
a. Skin rash, itching, and urticaria
b. Pallor, hypotension, and muscle cramping
c. Dry skin, bradycardia, fatigue, and headache
d. Headache, dyspnea, nausea, vomiting, and flushing
ANS: D
A disulfiram reaction consists of any combination of the following symptoms: flushing,
sweating, rapid pulse, hypotension, throbbing headache, nausea, vomiting, palpitations, dyspnea,
tremor, and weakness. The patient is acutely uncomfortable. The other options do not
characterize the disulfiram/alcohol reaction.
DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment
Steele: Keltner’s Psychiatric Nursing,
MULTIPLE CHOICE
1. The nurse suspect that a patient has developed a tolerance for alcohol. Which patient statement
supports that suspicion?
a. ―I felt good from drinking a six-pack a few months ago. Now I need a few extra
cans to get the same high.‖
b. ―I can stop drinking; I‘ve done it several times before.‖ c. ―I drink when I play cards with
the gang on weekends.‖ d. ―I‘ve been drinking most of adult life; I can handle it,‖.
ANS: A
Tolerance refers to the need for increasing amounts of a substance to achieve the same effects.
The other terms are not related to needing more of a substance to achieve the same effect.
DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment
, MSC: Client Needs: Psychosocial Integrity
2. Which statement made by the nurse best describes the experience of a patient who abuses
alcohol?
a. ―You can expect a comatose period related to alcohol withdrawal.‖
b. ―Alcohol intoxication and poisoning cause this state.‖
c. ―This is a time period in which a person who has used alcohol is unresponsive to
the environment.‖
d. This is an episode in which a person under the influence of alcohol functions
normally but later is unable to remember their actions.‖
ANS: D
A blackout is defined as a period of time in which a drinker functions socially but for which
there is no memory. The distracters omit aspects of a blackout.
DIF: Cognitive level: Evaluating TOP: Nursing process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. A patient diagnosed with Wernicke-Korsakoff syndrome has the nursing diagnosis impaired
memory, related to neurotoxicity of alcohol. Which statement made by the patient confirms the
presences of a defining characteristic that applies to this diagnosis?
a. ―I sometimes make up a story to cover up for something I can‘t remember.‖
b. ―I often hear voices that others claim they don‘t hear.‖
c. ―All of a sudden, I‘ll have a vivid memory of the accident that killed my son.‖
d. ―Regardless of what you say, I know that the mob or CIA is out to kill me.‖
ANS: A
Wernicke-Korsakoff syndrome is a mental disorder characterized by amnesia, clouding of
consciousness, confabulation (falsification of memory) and memory loss, and peripheral
neuropathy. Confabulation is a symptom typically displayed by an individual with Wernicke-
Korsakoff syndrome. The individual attempts to make up for memory loss by filling in the
, blanks with false memories. Auditory hallucinations are often described as hearing voices that no
one else can hear. Paranoid delusions are characterized by an
unrealistic or unsubstantiated belief that one is in danger. None of these options are symptoms of
memory impairment associated with Wernicke-Korsakoff syndrome.
DIF: Cognitive level: Analyzing TOP: Nursing process: Evaluation
MSC: Client Needs: Psychosocial Integrity
4. Which assessment findings would prompt the nurse to suspect a disulfiram reaction?
a. Skin rash, itching, and urticaria
b. Pallor, hypotension, and muscle cramping
c. Dry skin, bradycardia, fatigue, and headache
d. Headache, dyspnea, nausea, vomiting, and flushing
ANS: D
A disulfiram reaction consists of any combination of the following symptoms: flushing,
sweating, rapid pulse, hypotension, throbbing headache, nausea, vomiting, palpitations, dyspnea,
tremor, and weakness. The patient is acutely uncomfortable. The other options do not
characterize the disulfiram/alcohol reaction.
DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment
