Chapter 22: Substance-Related and Addictive Disorders Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition MULTIPLE CHOICE 1. A patient diagnosed with alcohol use disorder asks, “How will Alcoholics Anonymous (AA)
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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.” ANS: B
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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.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 22-48, 50, 51 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated.
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The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/minute 0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse’s priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.
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ANS: B
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Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. 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.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 22-31, 32, 38, 39 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3. A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has
the highest priority? a. Cardiovascular
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