Chapter 22 Substance Related and Addictive
Disorders UPDATED ACTUAL Exam
Questions and CORRECT Answers
1. A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?"
Select the nurse's best response.
a. "The goal of AA is for members to learn controlled drinking with the support of a higher
power."
b. "An individual is supported by peers while striving for abstinence one day at a time."
c. "You must make a commitment to permanently abstain from alcohol and other drugs."
d. "You will be assigned a sponsor who will plan your treatment program." - CORRECT
ANSWER -B
(Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time,
and receiving support from peers are basic aspects of AA. The other options are incorrect.)
2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated.
The medical record shows these blood pressure and pulse readings at the times listed:
0200: 118/78 mm Hg and 72 beats/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 148/94 mm Hg and 96 beats/min
What is the nurse's priority action?
a. Force fluids.
b. Consult the health care provider.
c. Obtain a clean-catch urine sample.
d. Place the patient in a vest-type restraint. - CORRECT ANSWER -B
,(Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for
medical intervention. No indication is present that the patient may have a urinary tract infection
or is presently in need of restraint. Hydration will not resolve the problem.)
3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has
the highest priority?
a. Cardiovascular
b. Respiratory
c. Neurologic
d. Hepatic - CORRECT ANSWER -B
(Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of
death among opioid abusers. The assessment of the other body systems is relevant but not the
priority. See relationship to audience response question.)
4. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours.
The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is
130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here."
Select the most accurate assessment of this 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 an acute psychosis. - CORRECT ANSWER -C
(Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal
delirium. The findings are inconsistent with manipulative attempts, head injury, or functional
psychosis.)
,5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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 - CORRECT ANSWER -D
(The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a
risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the
priorities of care.)
6. A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds
are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse
can anticipate the health care provider will prescribe a(n):
a. narcotic analgesic, such as hydromorphone (Dilaudid).
b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).
c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril).
d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil). - CORRECT
ANSWER -B
(Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in
most regions because of their high therapeutic safety index and anticonvulsant properties.)
7. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning
entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing
intervention is indicated?
a. Check the patient every 15 minutes
, b. One-on-one supervision
c. Keep the room dimly lit
d. Force fluids - CORRECT ANSWER -B
(One-on-one supervision is necessary to promote physical safety until sedation reduces the
patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety.
A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause
overhydration, because fluid retention normally occurs when blood alcohol levels fall.)
8. A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being
a single parent." Which therapeutic response by the nurse would help the patient conceptualize
the drinking 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." - CORRECT ANSWER -D
(The correct response will help the patient see alcohol as a cause of the problems, not a solution,
and begin to take responsibility. This approach can help the patient become receptive to the
possibility of change. The other 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. Select the nurse's best response.
"Alcoholics Anonymous is a:
a. form of group therapy led by a psychiatrist."
b. self-help group for which the goal is sobriety."
c. group that learns about drinking from a group leader."
d. network that advocates strong punishment for drunk drivers." - CORRECT ANSWER -
B
Disorders UPDATED ACTUAL Exam
Questions and CORRECT Answers
1. A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?"
Select the nurse's best response.
a. "The goal of AA is for members to learn controlled drinking with the support of a higher
power."
b. "An individual is supported by peers while striving for abstinence one day at a time."
c. "You must make a commitment to permanently abstain from alcohol and other drugs."
d. "You will be assigned a sponsor who will plan your treatment program." - CORRECT
ANSWER -B
(Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time,
and receiving support from peers are basic aspects of AA. The other options are incorrect.)
2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated.
The medical record shows these blood pressure and pulse readings at the times listed:
0200: 118/78 mm Hg and 72 beats/min
0400: 126/80 mm Hg and 76 beats/min
0600: 128/82 mm Hg and 72 beats/min
0800: 132/88 mm Hg and 80 beats/min
1000: 148/94 mm Hg and 96 beats/min
What is the nurse's priority action?
a. Force fluids.
b. Consult the health care provider.
c. Obtain a clean-catch urine sample.
d. Place the patient in a vest-type restraint. - CORRECT ANSWER -B
,(Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for
medical intervention. No indication is present that the patient may have a urinary tract infection
or is presently in need of restraint. Hydration will not resolve the problem.)
3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has
the highest priority?
a. Cardiovascular
b. Respiratory
c. Neurologic
d. Hepatic - CORRECT ANSWER -B
(Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of
death among opioid abusers. The assessment of the other body systems is relevant but not the
priority. See relationship to audience response question.)
4. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours.
The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is
130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here."
Select the most accurate assessment of this 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 an acute psychosis. - CORRECT ANSWER -C
(Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal
delirium. The findings are inconsistent with manipulative attempts, head injury, or functional
psychosis.)
,5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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 - CORRECT ANSWER -D
(The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a
risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the
priorities of care.)
6. A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds
are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse
can anticipate the health care provider will prescribe a(n):
a. narcotic analgesic, such as hydromorphone (Dilaudid).
b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).
c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril).
d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil). - CORRECT
ANSWER -B
(Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in
most regions because of their high therapeutic safety index and anticonvulsant properties.)
7. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning
entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing
intervention is indicated?
a. Check the patient every 15 minutes
, b. One-on-one supervision
c. Keep the room dimly lit
d. Force fluids - CORRECT ANSWER -B
(One-on-one supervision is necessary to promote physical safety until sedation reduces the
patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety.
A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause
overhydration, because fluid retention normally occurs when blood alcohol levels fall.)
8. A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being
a single parent." Which therapeutic response by the nurse would help the patient conceptualize
the drinking 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." - CORRECT ANSWER -D
(The correct response will help the patient see alcohol as a cause of the problems, not a solution,
and begin to take responsibility. This approach can help the patient become receptive to the
possibility of change. The other 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. Select the nurse's best response.
"Alcoholics Anonymous is a:
a. form of group therapy led by a psychiatrist."
b. self-help group for which the goal is sobriety."
c. group that learns about drinking from a group leader."
d. network that advocates strong punishment for drunk drivers." - CORRECT ANSWER -
B
