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A hypertensive client is admitted to the acute care facility that has a tobacco-free policy. Which nursing intervention would be most appropriate for the client who is a smoker?
- A. Allow the client to go outside to smoke.
- B. Anticipate withdrawal symptoms and treat accordingly.
- C. Contact the physician for a nonnicotine medication.
- D. Offer the client nicotine gum.
Correct Answer: C
Rationale: Nonnicotine medications such as Zyban and Chantix are dopamine uptake inhibitors that help suppress nicotine's addicting reinforcement. The order for these medications must be initiated by the physician and should lower the incidence of withdrawal symptoms for the client. Tobacco-free institutions do not permit smoking outdoors, and this activity should not be encouraged by the nurse. Offering nicotine gum without a physician's order is not appropriate. The nurse should anticipate withdrawal symptoms and provide kind supportive encouragement.
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A client has overdosed on opiates. Which drug would the nurse anticipate being ordered for this client?
- A. Dolphine
- B. Naltrexone
- C. Naloxone
- D. Hydromorphone
Correct Answer: C
Rationale: Opiate overdose leads to respiratory depression, unconsciousness, and death. Naloxone is administered to reverse the effects of opiates and assists in restoring respiration. Naltrexone is an opiate antagonist that is used for rapid opiate detoxification while the client is under anesthesia. Dolphine and hydromorphone are opiate drugs and would increase the effects of respiratory depression.
Which of the following refers to the reduction in a drug's effect that follows persistent use?
- A. Addiction
- B. Tolerance
- C. Withdrawal
- D. Dependence
Correct Answer: B
Rationale: Tolerance refers to the reduction in a drug's effect that follows persistent use. Addiction is drug-seeking behaviors that interfere with work, relationships, and normal activities. Withdrawal refers to the physical symptoms and craving for a drug that occur when a person abruptly stops using an abused substance. Dependence means that a person must take a drug to avoid withdrawal symptoms.
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.
The client who is experiencing alcohol withdrawal has a temperature of 100.6?°F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?
- A. Encourage the client to rest.
- B. Administer benzodiazepine as ordered.
- C. Monitor for any further changes.
- D. Provide emotional support.
Correct Answer: B
Rationale: The standardized symptom withdrawal flow sheet, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) as well as the Rule of One Hundreds are indicators of escalating withdrawal. The rise in these vital signs suggests the need for sedative medication. Monitoring hourly vital signs and further changes would be appropriate. Rest and emotional support can be helpful.
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.