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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.
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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.
A nurse is working with a client who is addicted to heroin. The nurse engages in harm reduction by teaching the client about which of the following?
- A. Using bleach solution to disinfect dirty needles
- B. Problem solving
- C. Healthy coping skills
- D. Proper use of naltrexone (Trexan)
Correct Answer: A
Rationale: Harm reduction in heroin addiction includes teaching needle disinfection with bleach (A) to reduce infection risk. Problem solving (B) and coping skills (C) are broader interventions, and naltrexone (D) is more relevant for alcohol or opioid relapse prevention.
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 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.
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.