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A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient withdrawal symptoms?
- A. Slurred speech, excessive drowsiness, and bradycardia
- B. Paranoid delusions, tactile hallucinations, and panic
- C. Runny nose, yawning, insomnia, and chills
- D. Anxiety, agitation, and aggression
Correct Answer: C
Rationale: Early narcotic withdrawal resembles flulike symptoms without fever.
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A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
- A. Substance abuse
- B. Substance addiction
- C. Substance intoxication
- D. Recreational use of a social drug
Correct Answer: B
Rationale: Nicotine addiction is indicated by compulsive use, craving, tolerance, and withdrawal symptoms.
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
- A. Make physical contact by frequently touching the patient.
- B. Offer intellectual activities requiring concentration.
- C. Avoid manipulation by denying the patient's requests.
- D. Observe for depression and suicidal ideation.
Correct Answer: D
Rationale: Rebound depression is common in CNS stimulant withdrawal, requiring monitoring for suicide risk.
In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats/min (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone. What is the priority outcome for this patient?
- A. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
- B. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department.
- C. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
- D. The patient will identify two community resources for the treatment of substance abuse by discharge.
Correct Answer: A
Rationale: Stabilizing vital signs is the priority for an opiate overdose.
A patient asks for information about the goals of Alcoholics Anonymous (AA). Which is the nurse's best response?
- A. It is a self-help group with the goal of sobriety.'
- B. It is a form of group therapy led by a psychiatrist.'
- C. It is a group that learns about drinking from a group leader.'
- D. It is a network that advocates strong punishment for drunk drivers.'
Correct Answer: A
Rationale: AA is a peer support group for recovering alcoholics with the goal of maintaining sobriety.
Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis?
- A. Powerlessness
- B. Disturbed thought processes
- C. Ineffective thermoregulation
- D. Impaired oral mucous membrane
Correct Answer: B
Rationale: Both conditions involve paranoid delusions, making disturbed thought processes appropriate.