1. Which assessment finding would alert the nurse to ask the patient about alcohol use?
a. Low blood pressure
b. Decreased heart rate
c. Elevated temperature
d. Abdominal tenderness
ANS: D
Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in patients with chronic alcohol use. The other
problems are not associated with alcohol abuse.
2. The nurse plans postoperative care for a patient who smokes a pack of cigarettes daily. Which goal should the nurse include in
the plan of care for this patient?
a. Improve sleep
b. Enhance appetite
c. Decrease diarrhea
1
,d. Prevent sore throat
2
,ANS: A
Insomnia is a characteristic of nicotine withdrawal. Diarrhea, sore throat, and anorexia are not symptoms associated with nicotine
withdrawal.
3. A young adult patient scheduled for an annual physical examination arrives in the clinic smelling of cigarette smoke and carrying
a pack of cigarettes. Which action will the nurse plan to take?
a. Urge the patient to quit smoking as soon as possible.
b. Avoid confronting the patient about smoking at this time.
c. Wait for the patient to start the discussion about quitting smoking.
d. Explain that the “cold turkey” method is most effective in stopping smoking.
ANS: A
Current national guidelines indicate that health care professionals should urge patients who smoke to quit smoking at every
encounter. The other actions will not help decrease the patient’s health risks related to smoking.
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
4. A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The
blood alcohol concentration (BAC) is 110 mg/dL (0.11 mg%). Which action by the nurse is mostappropriate?
a. Avoid the use of IV fluids.
b. Maintain the patient on NPO status.
3
, c. Administer acetaminophen for headache.
d. Monitor frequently for anxiety, hyperreflexia, and sweating.
ANS: D
The patient’s assessment data indicate probable physiologic dependence on alcohol, and the patient is likely to develop acute
withdrawal such as anxiety, hyperreflexia, and sweating, which could be life threatening. Acetaminophen is not recommended
because it is metabolized by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated patients to prevent
Wernicke’s encephalopathy, and there is no indication that the patient should be NPO.
5. An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing emergency surgery. What will the
nurse expect the patient to need during the perioperative period?
a. An increased dose of the general anesthetic medication
b. Frequent monitoring for bleeding and respiratory complications
c. Interventions to prevent withdrawal symptoms within a few hours
d. Stimulation every hour to prevent prolonged postoperative sedation
ANS: B
Patients who are intoxicated at the time of surgery are at increased risk for problems with bleeding and respiratory complications
such as aspiration. In an intoxicated patient, a lower dose of anesthesia is used because of the synergistic effect of the alcohol.
Withdrawal is likely to occur later in the postoperative course because the medications used for anesthesia, sedation, and pain will
delay withdrawal symptoms. The patient should be monitored frequently for oversedation but does not need to be stimulated.
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