Nokea
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 using motivational therapy with a female client with alcoholism. The client, who is unwilling to consider changing her drinking behavior, emphatically states, I am not an alcoholic; you can?t make me stop drinking. Which response by the nurse would be most appropriate?
- A. You have to stop drinking and driving; you could kill someone.
- B. You?re right; you?re not an alcoholic.
- C. You should consider what you are doing to your marital relationship.
- D. You?re the only one who can make yourself stop drinking.
Correct Answer: D
Rationale: Motivational interviewing emphasizes autonomy, making the response that only the client can choose to stop drinking (D) most appropriate. Confronting about driving (A) or relationships (C) may increase resistance, and agreeing with denial (B) is non-therapeutic.
A client is brought to the emergency department after having overdosed on cocaine. When assessing the client, which of the following would the nurse expect to find? Select all that apply.
- A. Euphoria
- B. Seizures
- C. Cardiac arrhythmia
- D. Paranoia
- E. Dilated pupils
Correct Answer: B,C,D,E
Rationale: Cocaine overdose can cause seizures (B), cardiac arrhythmia (C), paranoia (D), and dilated pupils (E) due to excessive CNS and sympathetic stimulation. Euphoria (A) is more typical of use, not overdose.
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.
A nurse is talking with a 57-year-old client who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit. It is 5:00 AM, and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that basically describes how her nursing supervisor came to visit and gave it to her to wear so she?d remember to get well. The nurse suspects that the client may be experiencing which of the following?
- A. Wernicke?s syndrome
- B. Delirium tremens
- C. Korsakoff?s psychosis
- D. Malignant hyperthermia
Correct Answer: C
Rationale: The client?s confabulation (fabricated story about the stethoscope) and insomnia suggest Korsakoff?s psychosis (C), a chronic condition from alcohol-related thiamine deficiency causing memory deficits. Wernicke?s syndrome (A) involves ataxia and confusion, delirium tremens (B) includes severe autonomic symptoms, and malignant hyperthermia (D) is unrelated to alcohol.
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).