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A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of relapse prevention?
- A. Rehearsing techniques to handle anticipated stressful situations
- B. Advising the patient to accept residential treatment if relapse occurs
- C. Assisting the patient to identify life skills needed for effective coping
- D. Isolating self from significant others and social situations until sobriety is established
- E. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances
Correct Answer: A,C,E
Rationale: Nurses can help with skill-building, stress management, and education on physiological changes to prevent relapse.
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A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who presents with what related characteristic?
- A. Jaundice
- B. Dependent on alcohol
- C. Healthy but underweight
- D. Facial abnormalities and cognitive impairment
Correct Answer: D
Rationale: Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder.
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dL. Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw?
- A. The patient rarely drinks alcohol.
- B. The patient has a high tolerance to alcohol.
- C. The patient has been treated with disulfiram.
- D. The patient has recently ingested both alcohol and sedative drugs.
Correct Answer: B
Rationale: A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dL. The patient's ability to walk and talk suggests tolerance.
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled 'lorazepam.' What is the nurse's first action?
- A. Test reflexes.
- B. Check pupils.
- C. Initiate vomiting.
- D. Establish a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority for an unconscious patient to prevent aspiration.
Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, what will the patient do?
- A. Use rationalization in healthy ways.
- B. State, 'I see the need for ongoing treatment.'
- C. Identify constructive outlets for expression of anger.
- D. Develop a trusting relationship with one staff member.
Correct Answer: B
Rationale: Recognizing the need for ongoing treatment is key to preventing relapse.
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.