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A 52-year-old male client who has a history of alcohol dependence is admitted to a detoxification unit. He has tremors, he is anxious, his pulse has risen from 98 to 110 beats/min, his blood pressure has risen from 140/88 to 152/100 mm Hg, and his temperature is six tenths of a degree above normal. He is slightly diaphoretic. Which nursing diagnosis would be the priority?
- A. Disturbed Thought Processes
- B. Risk for Injury
- C. Ineffective Coping
- D. Ineffective Denial
Correct Answer: B
Rationale: The client?s symptoms (tremors, anxiety, elevated vitals, diaphoresis) indicate early alcohol withdrawal, making Risk for Injury (B) the priority due to potential progression to seizures or delirium. Thought processes (A), coping (C), and denial (D) are secondary concerns.
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A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks the nurse, How will this drug help me? Which response by the nurse would be most appropriate?
- A. It will help to cure your alcoholism.
- B. It can help to prevent you from drinking.
- C. It makes the withdrawal symptoms less troublesome.
- D. It helps to clear the alcohol out of your body.
Correct Answer: B
Rationale: Disulfiram (B) prevents drinking by causing unpleasant reactions (e.g., nausea) if alcohol is consumed, acting as a deterrent. It does not cure alcoholism (A), reduce withdrawal symptoms (C), or clear alcohol from the body (D).
A client is brought into the emergency department because he was involved in an automobile accident. His blood alcohol level (BAL) is 0.10 mg %. Based on this finding, the nurse would expect to assess which of the following?
- A. Difficulty with coordination
- B. Stupor
- C. Emotional lability
- D. Ataxia
Correct Answer: A
Rationale: A BAL of 0.10 mg % (0.10 g/dL) typically causes difficulty with coordination (A), such as impaired motor skills. Stupor (B) occurs at higher levels (e.g., >0.30), emotional lability (C) is less specific, and ataxia (D) is more severe and less common at this level.
A nurse is obtaining a history from a client who drinks about 6 cups of coffee and several diet cola drinks per day. The client states, I just cut down my coffee and soda intake to one per day. Which of the following would the nurse most likely expect to assess? Select all that apply.
- A. Headache
- B. Fatigue
- C. Yawning
- D. Flushing
- E. Diuresis
Correct Answer: A,B,C
Rationale: Abrupt reduction in caffeine intake can cause withdrawal symptoms like headache (A), fatigue (B), and yawning (C) due to CNS and adenosine receptor changes. Flushing (D) and diuresis (E) are not typical caffeine withdrawal symptoms.
A client with a history of opioid abuse is exhibiting manifestations of moderate withdrawal. Which of the following would the nurse expect to assess?
- A. Rhinorrhea
- B. Lacrimation
- C. Dilated pupils
- D. Dysphoria
Correct Answer: A,B,C,D
Rationale: Moderate opioid withdrawal includes rhinorrhea (A), lacrimation (B), dilated pupils (C), and dysphoria (D) due to autonomic and psychological distress. All are characteristic symptoms.
A client tells the nurse that he is committed to trying to quit smoking. When teaching the client about smoking cessation, which of the following would the nurse include?
- A. Success usually involves more than one type of intervention.
- B. Relapse is fairly rare within the first year of quitting.
- C. Ear acupressure is a highly proven method for quitting.
- D. Education is key for smoking cessation.
Correct Answer: A
Rationale: Smoking cessation success typically requires multiple interventions (A), such as behavioral therapy, medications, and support groups. Relapse is common in the first year (B), ear acupressure (C) lacks strong evidence, and education alone (D) is insufficient.