Psychiatric Mental Health Nursing
Chapter 25
Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan
for the client who is in withdrawal must include which nursing interventions?
A: Vital signs and medications as prescribed
B: Observation for symptoms, vital signs, seizure and fall precautions, medications as
ordered
C: Suicide precautions because suicide attempts are frequent during withdrawal
D: Seizure precautions and vital signs - CORRECT ANSWER-B
Nursing care of the client experiencing withdrawal centers on safety first. The nurse
must implement frequent vital sign assessment, seizure precautions, and fall
precautions to ensure the client's safety. Withdrawal symptoms must be controlled with
medications.
Which statement most accurately describes the etiology of substance-related disorders?
A: Substance-related disorders result from the interplay of biologic, genetic, and
psychosocial factors.
B: Substance-related disorders are primarily a result of the presence of an individual's
inherently addictive personality.
C: The primary predictors of substance-related disorders are childhood trauma and
parental abuse or neglect.
D: Substance abuse is a learned behavior - CORRECT ANSWER-A
Rationale: Substance-related disorders have a complex etiology, and contributions have
been noted from a combination of neurological, genetic, behavioral, and sociocultural
sources.
The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse
that his relationship with the client was codependent and enabling. Which of the
following is an example of codependent behavior?
A: The friend called Alcoholics Anonymous when the client expressed a need to stop
drinking.
B:The friend called the client every night to make sure he got home safely, and went
looking for him if he was not at home.
C: The friend confronted the client on the effect of his drinking on their relationship.
D: The friend refused to go out drinking with the client to celebrate the client's birthday. -
CORRECT ANSWER-B
, Rationale: Codependent behavior appears helpful on the surface but actually prolongs
the drinking behavior. Answers A, C, and D are not examples of codependent behavior.
Disulfiram should not be administered until a client has abstained from alcohol for at
least how long?
A: 12 hours
B: 4 hours
C: 8 hours
D: 16 hours - CORRECT ANSWER-A
Rationale: Warnings related to disulfiram include never administering the drug to an
intoxicated client or without the client's knowledge, and not administering the drug until
the client has abstained from alcohol for at least 12 hours.
Which characteristic of the 12-step program distinguishes it from other programs?
A: The philosophy that it is possible to reduce the use of substances without abstaining.
B: It is a self-help group that focuses on total abstinence.
C: Persons who use this program are independent in their sobriety.
D: Infrequent attendance is usually successful. - CORRECT ANSWER-B
Rationale: Alcoholics Anonymous was founded in the 1930s by alcoholics. This self-
help group developed the 12-step program model for recovery, which is based on the
philosophy that total abstinence is essential and that alcoholics need the help and
support of others to maintain sobriety. Regular attendance at meetings is emphasized.
A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen
in the emergency department. The nurse assesses the client and finds the client is
oriented but is tremulous, weak, and sweaty and has some gastrointestinal (GI)
symptoms. Which is typical of these symptoms?
A: Alcohol withdrawal syndrome
B: Continuing intoxication
C: Delirium tremens
D: Wernicke-Korsakoff syndrome - CORRECT ANSWER-A
Rationale: Withdrawal from alcohol produces shakiness, weakness, diaphoresis, and GI
symptoms. These are not symptoms of continuing intoxication. Delirium tremens
produce hypertension, delusions, hallucinations, and agitated behavior. Wernicke-
Korsakoff syndrome is a type of dementia caused by long-term, excessive alcohol
intake that results in a chronic thiamine or vitamin B6 deficiency.
The client was diagnosed with cocaine abuse at age 30. When the client was 23, the
client was diagnosed with major depressive episode, and has continued to have
depression off and on since then. Which statement would reflect this situation?
A: The client is probably using cocaine in combination with her antidepressants to
enhance the effects of the cocaine.
Chapter 25
Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan
for the client who is in withdrawal must include which nursing interventions?
A: Vital signs and medications as prescribed
B: Observation for symptoms, vital signs, seizure and fall precautions, medications as
ordered
C: Suicide precautions because suicide attempts are frequent during withdrawal
D: Seizure precautions and vital signs - CORRECT ANSWER-B
Nursing care of the client experiencing withdrawal centers on safety first. The nurse
must implement frequent vital sign assessment, seizure precautions, and fall
precautions to ensure the client's safety. Withdrawal symptoms must be controlled with
medications.
Which statement most accurately describes the etiology of substance-related disorders?
A: Substance-related disorders result from the interplay of biologic, genetic, and
psychosocial factors.
B: Substance-related disorders are primarily a result of the presence of an individual's
inherently addictive personality.
C: The primary predictors of substance-related disorders are childhood trauma and
parental abuse or neglect.
D: Substance abuse is a learned behavior - CORRECT ANSWER-A
Rationale: Substance-related disorders have a complex etiology, and contributions have
been noted from a combination of neurological, genetic, behavioral, and sociocultural
sources.
The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse
that his relationship with the client was codependent and enabling. Which of the
following is an example of codependent behavior?
A: The friend called Alcoholics Anonymous when the client expressed a need to stop
drinking.
B:The friend called the client every night to make sure he got home safely, and went
looking for him if he was not at home.
C: The friend confronted the client on the effect of his drinking on their relationship.
D: The friend refused to go out drinking with the client to celebrate the client's birthday. -
CORRECT ANSWER-B
, Rationale: Codependent behavior appears helpful on the surface but actually prolongs
the drinking behavior. Answers A, C, and D are not examples of codependent behavior.
Disulfiram should not be administered until a client has abstained from alcohol for at
least how long?
A: 12 hours
B: 4 hours
C: 8 hours
D: 16 hours - CORRECT ANSWER-A
Rationale: Warnings related to disulfiram include never administering the drug to an
intoxicated client or without the client's knowledge, and not administering the drug until
the client has abstained from alcohol for at least 12 hours.
Which characteristic of the 12-step program distinguishes it from other programs?
A: The philosophy that it is possible to reduce the use of substances without abstaining.
B: It is a self-help group that focuses on total abstinence.
C: Persons who use this program are independent in their sobriety.
D: Infrequent attendance is usually successful. - CORRECT ANSWER-B
Rationale: Alcoholics Anonymous was founded in the 1930s by alcoholics. This self-
help group developed the 12-step program model for recovery, which is based on the
philosophy that total abstinence is essential and that alcoholics need the help and
support of others to maintain sobriety. Regular attendance at meetings is emphasized.
A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen
in the emergency department. The nurse assesses the client and finds the client is
oriented but is tremulous, weak, and sweaty and has some gastrointestinal (GI)
symptoms. Which is typical of these symptoms?
A: Alcohol withdrawal syndrome
B: Continuing intoxication
C: Delirium tremens
D: Wernicke-Korsakoff syndrome - CORRECT ANSWER-A
Rationale: Withdrawal from alcohol produces shakiness, weakness, diaphoresis, and GI
symptoms. These are not symptoms of continuing intoxication. Delirium tremens
produce hypertension, delusions, hallucinations, and agitated behavior. Wernicke-
Korsakoff syndrome is a type of dementia caused by long-term, excessive alcohol
intake that results in a chronic thiamine or vitamin B6 deficiency.
The client was diagnosed with cocaine abuse at age 30. When the client was 23, the
client was diagnosed with major depressive episode, and has continued to have
depression off and on since then. Which statement would reflect this situation?
A: The client is probably using cocaine in combination with her antidepressants to
enhance the effects of the cocaine.
