behaviours test 2024-2025 questions with
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After a long history of intravenous heroin use, a client has expressed a willingness to stop using heroin.
The nurse would expect the client to receive which medication to decrease the severity of withdrawal?
a) Methadone
b) Gabapentin (Neurontin)
c) Ondansetron (Zofran)
d) Amphetamines - ANSWERS -a) Methadone
A nurse evaluates a client's 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 dependence?
A. Narcotic pain medication is contraindicated for all clients with active substance abuse problems.
B. Clients who are dependent on 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 dependence. There is an obvious PCA malfunction.
D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam
(Ativan) dosage. - ANSWERS -ANS: B
The nurse should assess the client for substance dependence because clients who are dependent on
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 lessened the client's
response to another drug.
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 - ANSWERS -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.
On the first day of a client's 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 dosage according to protocol.
D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome. - ANSWERS -ANS: C
The priority nursing intervention for this client should be to administer ordered chlordiazepoxide
(Librium) in 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 the
life-threatening effects of the rebound stimulation of the central nervous system that occurs during
withdrawal.
Which client statement indicates a knowledge deficit related to substance abuse?
A. "Although it's 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. It's essentially harmless." - ANSWERS -ANS: D
The nurse should determine that the client has a knowledge deficit related to substance abuse when the
client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second
most widely abused drug in the United States.
A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term
should a nurse use to best describe this individual's situation?
,A. The individual is experiencing psychological dependency.
B. The individual is experiencing physical dependency.
C. The individual is experiencing substance dependency.
D. The individual is experiencing social dependency. - ANSWERS -ANS: A
The nurse should use the term "psychological dependency" to best describe this client's situation. A
client is considered to be psychologically dependent on a substance when there is an overwhelming
desire to use a substance in order to produce pleasure or avoid discomfort.
Which term should a nurse use to describe the administration of a central nervous system (CNS)
depressant during alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Substitution therapy - ANSWERS -ANS: D
A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent
life-threatening symptoms that occur because of the rebound reaction of the central nervous system.
A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment
facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most
appropriate for a nurse to discuss with the client during discharge teaching?
A. After discharge, the client will immediately attend 90 AA meetings in 90 days.
B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C. After discharge, the client will incorporate family in AA attendance.
D. After discharge, the client will seek appropriate deterrent medications through AA. - ANSWERS -ANS:
A
The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90
AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of
alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.
, A client with a history of heavy alcohol use is brought to an emergency department (ED) by family
members who state that the client has had nothing to drink in the last 24 hours. Which client symptom
should the nurse immediately report to the ED physician?
A. Tactile hallucinations
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on a numeric scale
D. Dehydration - ANSWERS -ANS: B
The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should
promptly report this finding to the physician. Complications associated with alcohol withdrawal may
progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day
following cessation of prolonged alcohol consumption.
Which client statement demonstrates positive progress toward recovery from substance abuse?
A. "I have completed detox and therefore am in control of my drug use."
B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings."
C. "As a church deacon, my focus will now be on spiritual renewal."
D. "Taking those pills got out of control. It cost me my job, marriage, and children." - ANSWERS -ANS: D
A client who takes responsibility for the consequences of substance abuse/dependence is making
positive progress toward recovery. This client would most likely be in the working phase of the
counseling process in which acceptance of the fact that substance abuse causes problems occurs.
A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this
intervention?
A. To assess for emotional strength
B. To assess for Wernicke-Korsakoff syndrome
C. To assess for tachycardia
D. To assess for fine tremors - ANSWERS -ANS: D. To assess for fine tremors