Nokea
A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?
- A. Cardiac problems
- B. Respiratory problems
- C. Withdrawal problems
- D. Circulatory problems
Correct Answer: C
Rationale: Diaphoresis, tremors, and hypertension are all symptoms of withdrawal from alcohol consumption. The nurse, concerned about the patient's medical condition, may not consider substance abuse until withdrawal symptoms appear.
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What should the nurse do to decrease the patient's disorientation at night during the detoxification period?
- A. Place the patient in a room with another recovering patient.
- B. Instruct the patient to orient himself to his surroundings at bedtime.
- C. Wake the patient up every 4 hours to eat a small snack.
- D. Use nightlights and remove extra furniture from the room.
Correct Answer: D
Rationale: Use of nightlights and removing extra furniture that could be misidentified will reduce disorientation. The patient should not be woken up to eat, but if he is awake, small snacks can be offered. The nurse should orient the patient to his surroundings.
The nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement?
- A. I drink because I'm lonely.
- B. All my difficulties are related to my drinking.
- C. I wouldn't need to drink if I had my family back.
- D. My drinking helps me cope with the stress of my job.
Correct Answer: B
Rationale: A major goal for the successful treatment of alcoholics is to have them express responsibility for their behavior.
While creating a methadone protocol for a patient rehabilitating from heroin addiction, the nurse explains that the patient will take methadone for what length of time?
- A. Daily for the rest of his life.
- B. Daily until stabilized, then gradually reduce the dose to zero.
- C. Weekly for at least 6 months, then decrease the dose to once a month.
- D. Monthly for 6 to 10 months, then decrease the dose to zero.
Correct Answer: B
Rationale: Methadone is given daily until the patient is stabilized. The methadone is reduced gradually until the patient does not need to take any.
If the patient tells the nurse, 'I'm not an alcoholic. I can stop whenever I want to,' what should be the nurse's most therapeutic response?
- A. Well, why don't you?
- B. Hasn't alcohol use interfered with your employment?
- C. A positive attitude like that is a good start.
- D. What would you call alcoholism?
Correct Answer: B
Rationale: When the addicted person presents in denial, the nurse should use techniques to set limits on that behavior.
During the initial intake assessment of a drug user, the nurse should attempt to obtain which subjective data?
- A. Usual pattern of use
- B. Specific drug
- C. Previous arrests
- D. Amount of drug used
- E. Time of last use
Correct Answer: A,B,D,E
Rationale: Determining the drug, strength, frequency, last use, and pattern of use is the basic database on a substance abuser.