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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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The nurse is completing the admission of a client who is seeking treatment for alcoholism. He tells the nurse that the last time he had any alcohol to drink was at 10:00 AM before he left for the hospital. The nurse closely monitors the client. Which of the following would lead the nurse to suspect that the client is experiencing stage 1 of alcohol withdrawal syndrome? Select all that apply.
- A. Slight diaphoresis
- B. Hand tremors
- C. Intermittent confusion
- D. Heart rate of 135 beats/min
- E. Normal blood pressure
Correct Answer: A,B,E
Rationale: Stage 1 alcohol withdrawal (6?24 hours post-last drink) includes slight diaphoresis (A), hand tremors (B), and normal blood pressure (E). Intermittent confusion (C) and heart rate of 135 (D) are more typical of later stages like delirium tremens.
A group of nursing students is reviewing information about substances that are abused. The students demonstrate understanding of the information when they identify which of the following as stimulants? Select all that apply.
- A. Alcohol
- B. Cocaine
- C. Heroin
- D. Nicotine
- E. Phencyclidine
Correct Answer: B,D
Rationale: Cocaine (B) and nicotine (D) are stimulants, increasing CNS activity. Alcohol (A) is a depressant, heroin (C) is an opioid, and phencyclidine (E) is a dissociative anesthetic.
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.
An adolescent client tells the nurse that he or she occasionally sniffs airplane glue. When discussing the effects of long-term use of inhalants, which of the following would the nurse most likely include?
- A. Tremors and CNS arousal
- B. Enhanced normal heart rhythms
- C. Enhanced attention focus and memory
- D. Brain damage and cognitive abnormalities
Correct Answer: D
Rationale: Long-term inhalant use, such as sniffing glue, causes brain damage and cognitive abnormalities (D) due to neurotoxicity. Tremors and CNS arousal (A) are acute effects, heart rhythms (B) are disrupted, and attention/memory (C) are impaired, not enhanced.
A nurse is implementing a brief intervention with a client who is abusing alcohol. The nurse most likely would be involved with which of the following?
- A. Asking the client questions about alcohol use
- B. Negotiating a conversation with the client to reduce use
- C. Pointing out the inconsistencies in thoughts, feelings, and action
- D. Helping the client change the way he thinks about a situation
Correct Answer: B
Rationale: Brief interventions for alcohol abuse involve negotiating a conversation to reduce use (B), using motivational techniques to encourage change. Asking questions (A) is part of assessment, pointing out inconsistencies (C) is confrontational, and changing thinking (D) is more cognitive therapy.