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 process r/t tactile hallucinations C. Ineffective coping r/t powerlessness over alcohol use D. Ineffective denial r/t continued ...
NUR 313 Exam 2 Questions and Correct
Answers
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 process r/t tactile hallucinations
C. Ineffective coping r/t powerlessness over alcohol use
D. Ineffective denial r/t continued alcohol use despite negative consequences ✅1
A nurse evaluates a client's patient-controlled analgesia (pca) pump and notice 100
attempts within a 30-minute period. Which is the best rationale for assessing this client
for substance addiction?
A. Narcotic pain medication is contraindicated for all clients with substance abuse
disorders
B. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance
to analgesics and require increased doses to achieve effective pain control
C. There is no need to assess the client for substance addiction. There is an obvious
pca malfunction, because these clients have a higher pain tolerance
D. The client is experiencing alcohol withdrawal symptoms and needs accurate
assessment ✅2
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 (aa) meetings in 90
days
B. Educate the client about 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 ✅3
Which client statement indicates a knowledge deficit related to a substance use
disorder?
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 lysergic diethylamide (lsd) use may reoccur"
D. "marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless"
✅4
A lonely, depressed divorcee has been self-medicating with small amounts of cocaine
for the past year. Which term should a nurse use to best describe the individual's
situation?
A. Psychological dependence
B. Codependence
,C. Substance induced disorder
D. Social induced disorder ✅1
Which term should a nurse use to describe the administration of a central nervous
system (cns) depressant during the substance induced disorder of alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Substitution therapy ✅4
A client diagnosed with chronic alcohol addiction is being discharged from an inpatient
treatment facility after detoxification. Which client outcome, related to aa, would be most
appropriate for the 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
✅1
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 48
hours. When the nurse reports to the ed physician, which client symptom should be the
nurse's first priority?
A. Hearing and visual impairment
B. Blood pressure of 180/100 mm hg
C. Mood rating of 2/10 on numeric scale
D. Dehydration ✅2
Which client statement demonstrates positive progress toward recovery from a
substance use disorder?
A. "i have completed detox and therefore am in control of my drug use:
B. "i will faithfully attend narcotic anonymous when i can't control my cravings"
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" ✅4
A nurse holds the hands of a client who is withdrawing from alcohol. What is the nurse's
rationale for this intervention?
A. To assess emotional strength
B. To assess for wernicke-korsakoff syndrome
C. To assess for tachycardia
D. To assess for fine tremors ✅4
A client presents with symptoms of alcohol withdrawal and states "i haven't eaten in
three days." a nurse's assessments reveals bp 170/100 mm hg, hr 110, rr 28, and
temperature 97 degrees f with 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 ✅3
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. "i think you should start to confront his behavior"
C. "your husband needs to deal with consequences of his drinking"
D. "do you understand what the term enabler means?" ✅3
Which medication orders should a nurse anticipate for a client who has a history of
benzodiazepine-withdrawal delirium?
A. Haloperidol (haldol) and fluoxetine (prozac)
B. Carbamazepine (tegretol) and donepezil (aricept)
C. Disulfiram (antabuse) and lorazepam (ativan)
D. Chlordiazepoxide (librium) and phenytoin (dilantin) ✅4
A nurse is reviewing the stat laboratory data of a client 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 ✅2
A client diagnosed with major depressive disorder episode and substance use disorder
has an altered sleep pattern demands psychiatrist to 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 their effectiveness will be
compromised owing to tolerance
B. Sedative-hypnotics are expensive and have numerous side effects
C. Sedative-hypnotics interfere with necessary rem sleep
D. Sedative-hypnotics are known not to be as effective in promoting sleep as
antidepressant medications ✅1
A client diagnosed with a gambling disorder asks the nurse about medications that may
be ordered by the client's physician to treat this disorder. The nurse would give the
client information on which medications?
A. Escitalopram (lexapro) and clozapine (clozaril)
B. Citalopram (celexa) and olanzapine (zyprexa)
C. Lithium carbonate (lithobid) and sertraline (zoloft)
D. Naltrexone (revia) and ziprasidone (geodon) ✅3
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