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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.
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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.
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, 'After discharge, I think everything will be just fine.' Which remark by the nurse will be most helpful to the spouse?
- A. It is good that you're supportive of your spouse's sobriety and want to help maintain it.'
- B. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.'
- C. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.'
- D. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully.'
Correct Answer: B
Rationale: This response provides anticipatory guidance about challenges in sobriety, helping the spouse prepare for new issues.
A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling?
- A. Conveying understanding that pressures associated with nursing practice underlie substance abuse
- B. Pointing out that work problems are the result, but not the cause, of substance abuse
- C. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing
- D. Providing health teaching about stress management
Correct Answer: A
Rationale: Enabling denies the seriousness of the problem or shifts responsibility from the individual.
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.
A patient admitted to an alcoholism rehabilitation program says, 'I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening.' The patient is using which defense mechanism?
- A. Rationalization
- B. Introjection
- C. Projection
- D. Denial
Correct Answer: D
Rationale: Minimizing drinking is a form of denial of alcoholism.