Chapter 25: Substance-Related Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____	1.	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	

____	2.	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.	

____	3.	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 a dosage according to protocol.	
D.	Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.	

____	4.	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.”	

____	5.	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.	

____	6.	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	

____	7.	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.	

____	8.	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 immediate report to the ED physician?
A.	Tactile hallucinations	
B.	Blood pressure of 180/100 mm Hg	
C.	Mood rating of 2/10 on numeric scale	
D.	Dehydration	

____	9.	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.”	

____	10.	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	

____	11.	Upon admission for symptoms of alcohol withdrawal a client states, “I haven’t eaten in 3 days.” Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?
A.	Knowledge deficit	
B.	Fluid volume excess	
C.	Imbalanced nutrition: less than body requirements	
D.	Ineffective individual coping	

____	12.	A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?
A.	“I’m not going to use heroin ever again. I know I’ve got the willpower to do it this time.”	
B.	“I cannot control my use of heroin. It’s stronger than I am.”	
C.	“I’m going to get all my children back. They need their mother.”	
D.	“Once I deal with my childhood physical abuse, recovery should be easy.”	

____	13.	A client’s wife has been making excuses for her alcoholic husband’s work absences. In family therapy, she states, “His problems at work are my fault.” Which is the appropriate nursing response?
A.	“Why do you assume responsibility for his behaviors?”	
B.	“Codependency is a typical behavior of spouses of alcoholics.”	
C.	“Your husband needs to deal with the consequences of his drinking.”	
D.	“Do you understand what the term ‘enabler’ means?”	

____	14.	Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?
A.	Haloperidol (Haldol) and fluoxetine (Prozac)	
B.	Carbamazepine (Tegretol) and donepezil (Aricept)	
C.	Disulfiram (Antabuse) and lorazepan (Ativan)	
D.	Chlordiazepoxide (Librium) and phenytoin (Dilantin)	

____	15.	During group therapy, a client diagnosed with chronic alcohol dependence states, “I would not have boozed it up if my wife hadn’t been nagging me all the time to get a job. She never did think that I was good enough for her.” How should a nurse interpret this statement?
A.	The client is using denial by avoiding responsibility.	
B.	The client is using displacement by blaming his wife.	
C.	The client is using rationalization to excuse his alcohol dependence.	
D.	The client is using reaction formation by appealing to the group for sympathy.	

____	16.	A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
A.	The client will identify one person to turn to for support.	
B.	The client will give up all old drinking buddies.	
C.	The client will be able to verbalize the effects of alcohol on the body.	
D.	The client will correlate life problems with alcohol use.	

____	17.	A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
A.	50 mg/dL	
B.	100 mg/dL	
C.	250 mg/dL	
D.	300 mg/dL	

____	18.	A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms?
A.	Between 3 a.m. and 11 a.m.	
B.	Shortly after a 24-hour period	
C.	At the beginning of the third day	
D.	Withdrawal is individualized and cannot be predicted.	

____	19.	A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?
A.	Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.	
B.	Sedative-hypnotics are expensive and have numerous side effects.	
C.	Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.	
D.	Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.	

____	20.	A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem?
A.	Ineffective coping R/T unresolved anxiety AEB substance abuse	
B.	Anxiety R/T poor sleep AEB difficulty falling asleep	
C.	Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep	
D.	Risk for injury R/T addiction to Librium	

____	21.	A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess?
A.	Gross tremors, delirium, hyperactivity, and hypertension	
B.	Disorientation, peripheral neuropathy, and hypotension	
C.	Oculogyric crisis, amnesia, ataxia, and hypertension	
D.	Hallucinations, fine tremors, confabulation, and orthostatic hypotension	

____	22.	A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse?
A.	Alcohol poisoning	
B.	Cardiovascular accident (CVA)	
C.	A reaction to disulfiram (Antabuse)	
D.	A reaction to tannins in the red wine	

____	23.	A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse?
A.	“This medication will help you maintain your abstinence.”	
B.	“This medication will cause uncomfortable symptoms if you combine it with alcohol.”	
C.	“This medication will decrease the effect alcohol has on your body.”	
D.	“This medication will lower your risk of experiencing a complicated withdrawal.”	

____	24.	A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication?
A.	“Only oral ingestion of alcohol will cause a reaction when taking this drug.”	
B.	“It is safe to drink beverages that have only 12% alcohol content.”	
C.	“This medication will decrease your cravings for alcohol.”	
D.	“Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug.”	

____	25.	Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?
A.	Darken the room to reduce stimuli in order to prevent seizures.	
B.	Assess aggressive behaviors in order to intervene to prevent injury to self or others.	
C.	Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system.	
D.	Teach the negative effects of alcohol on the body.	

____	26.	A client diagnosed with alcohol abuse joins a community 12-step program and states, “My life is unmanageable.” How should the nurse interpret this client’s statement?
A.	The client is using minimization as an ego defense.	
B.	The client is ready to sign an Alcoholics Anonymous contract for sobriety.	
C.	The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous.	
D.	The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.	

____	27.	In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention?
A.	Dextroamphetamine (Dexedrine)	
B.	Diazepam (Valium)	
C.	Morphine (Astramorph)	
D.	Phencyclidine (PCP)	

____	28.	The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?
A.	By asking directly if the client has ever had a problem with alcohol	
B.	By holistically assessing the client using the CIWA scale	
C.	By using a screening tool such as the CAGE questionnaire	
D.	By referring the client for physician evaluation	

Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____	29.	Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.)
A.	“I am easily manipulated and need to work on this prior to caring for these clients.”	
B.	“Because of my father’s alcoholism, I need to examine my attitude toward these clients.”	
C.	“I need to review the side effects of the medications used in the withdrawal process.”	
D.	“I’ll need to set boundaries to maintain a therapeutic relationship.”	
E.	“I need to take charge when dealing with clients diagnosed with substance disorders.”	

____	30.	A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.)
A.	“A diet rich in protein will promote hepatic healing.”	
B.	“This condition leads to a rise in serum ammonia resulting in impaired mental functioning.”	
C.	“In this condition, blood accumulates in the abdominal cavity.”	
D.	“Neomycin and lactulose are used in the treatment of this condition.”	
E.	“This condition is caused by the inability of the liver to convert ammonia to urea.”	

Chapter 25: Substance-Related Disorders
Answer Section

MULTIPLE CHOICE

	1.	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.

PTS:	1	REF:	505	
KEY:	Cognitive Level: Analysis | Integrated Process: Diagnosis

	2.	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.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	3.	ANS:	C
The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a 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 life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

PTS:	1	REF:	504	
KEY:	Cognitive Level: Analysis | Integrated Process: Implementation	

	4.	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.

PTS:	1	REF:	479	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	5.	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.

PTS:	1	REF:	457	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	6.	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.

PTS:	1	REF:	504	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	7.	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.

PTS:	1	REF:	500	
KEY:	Cognitive Level: Application | Integrated Process: Planning	

	8.	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.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	9.	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.

PTS:	1	REF:	496	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	10.	ANS:	D
The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

PTS:	1	REF:	484	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	11.	ANS:	C
The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

PTS:	1	REF:	496	
KEY:	Cognitive Level: Analysis | Integrated Process: Diagnosis

	12.	ANS:	B
A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

PTS:	1	REF:	495	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	13.	ANS:	C
The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client’s wife may be in denial and enabling the husband’s behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

PTS:	1	REF:	493	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	14.	ANS:	D
The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

PTS:	1	REF:	504	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	15.	ANS:	C
The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

PTS:	1	REF:	494	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	16.	ANS:	D
To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

PTS:	1	REF:	492	
KEY:	Cognitive Level: Application | Integrated Process: Planning	

	17.	ANS:	B
The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	18.	ANS:	A
The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	19.	ANS:	A
The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	20.	ANS:	C
Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

PTS:	1	REF:	457	
KEY:	Cognitive Level: Analysis | Integrated Process: Diagnosis

	21.	ANS:	A
Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	22.	ANS:	C
Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

PTS:	1	REF:	501	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	23.	ANS:	A
Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

PTS:	1	REF:	503	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	24.	ANS:	D
If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

PTS:	1	REF:	502	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	25.	ANS:	B
Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

PTS:	1	REF:	491	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	26.	ANS:	C
The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

PTS:	1	REF:	500	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	27.	ANS:	B
If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

PTS:	1	REF:	465	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	28.	ANS:	C
The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three “yes” answers strongly suggests a problem with alcohol.

PTS:	1	REF:	489	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

MULTIPLE RESPONSE

	29.	ANS:	A, B, D
The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse’s ability to establish therapeutic relationships with these clients.

PTS:	1	REF:	481	
KEY:	Cognitive Level: Application | Integrated Process: Implementation	

	30.	ANS:	A, C
The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing and that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

PTS:	1	REF:	463	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation