Nokea
A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?
- A. Tolerance
- B. Addiction
- C. Alcoholism
- D. Relapse
Correct Answer: A
Rationale: Tolerance occurs when the body develops mechanisms to reduce the effects of a drug through persistent use. This results in the need to increase the amount of a substance to obtain the desired effect. Addiction is a term that refers to drug-seeking behavior that interferes with work, relationships, and normal activities. Alcoholism is a chronic, progressive disease characterized by an inability to control the consumption of alcohol in which tolerance develops. Relapse is a term referring to the return to drug or alcohol use after a period of abstinence.
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Which of the following assessment findings is observed in a client with opiate use?
- A. Diarrhea
- B. Pinpoint-sized pupils
- C. Weight gain
- D. Bulimia
Correct Answer: B
Rationale: The assessment findings in a client with opiate use are pinpoint-sized pupils, constipation, weight loss, and anorexia. Diarrhea, weight gain, and bulimia are not the assessment findings observed in a client with opiate dependency.
Clinical manifestations of methamphetamine use include which of the following?
- A. Weight gain
- B. Moist mucous membranes
- C. Acne
- D. Vasodilation of blood vessels
Correct Answer: C
Rationale: Methamphetamine users may develop acne and be covered with multiple scratched areas because they believe that insects are crawling under their skin. The client will have dry mucous membranes, weight loss, and vasoconstriction of blood vessels.
The client who reports drinking half a case of beer each day is admitted for detoxification. Which answer explains the onset of withdrawal symptoms 4 hours after last reported drink?
- A. The client will progress through detox faster than expected.
- B. Early onset of withdrawal symptoms indicates incorrect reporting of the time of last use.
- C. Three hours is the normal onset for withdrawal symptoms to begin.
- D. The withdrawal process will take about 24 hours from time of onset.
Correct Answer: B
Rationale: Alcohol withdrawal usually begins 6 hours after last drink. This client has incorrectly reported the time of last use. The withdrawal process from alcohol usually takes about 48 hours or more.
What assessment finding(s) is most important in determining the presence of alcohol dependency in a client? Select all that apply.
- A. Patterns of use
- B. Weight loss
- C. Fluctuation in appetite
- D. Absenteeism from work
- E. Blurred vision
- F. Blackouts
Correct Answer: A,D,F
Rationale: People who are dependent on alcohol are driven by the pattern of use and how or when to obtain alcohol. They begin drinking earlier in the day and create opportunities to drink. Loss of work hours, especially on Mondays, becomes a pattern. Blackouts or loss of episodes of time can occur in the early and later stages of the abuse. Weight loss and fluctuation in appetite may be associated with alcohol use disorder but is not a determining factor. Blurred vision is not significant in the assessment of the disorder.
A client who has attempted to quit smoking and failed two times before is reluctant to make another attempt. Which response by the nurse is most appropriate?
- A. You will know when the time is right.
- B. Most people who have tried and failed ultimately do succeed.
- C. Tell me what you have tried before and we can make changes to your plan.
- D. I know you can do it this time.
Correct Answer: B
Rationale: Attempts to quit are a predictor of eventual success, and many of those who have tried and failed do ultimately succeed. Providing the client with this encouragement supports the desire to quit. Waiting until the time is right may postpone the urge to quit. The nurse does not 'know' for certainty that a client is going to achieve a goal but can be a supporter during the process. Although having a plan to follow is important, the support and encouragement to take the first step is the springboard.