Nokea
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
- A. Disturbed sensory perception
- B. Ineffective coping
- C. Ineffective denial
- D. Risk for injury
Correct Answer: D
Rationale: Clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety has a higher priority.
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A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
- A. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
- B. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
- C. About 0200 on hospital day 3 (72 hours after drinking stopped)
- D. About 0200 on hospital day 4 (96 hours after drinking stopped)
Correct Answer: B
Rationale: Alcohol withdrawal usually begins 2 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.
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.
Which treatment approach is most appropriate for a patient with poor social skills who has been treated several times for substance addiction but has relapsed?
- A. 1-week detoxification program
- B. Long-term outpatient therapy
- C. 12-step self-help program
- D. Residential program
Correct Answer: D
Rationale: Residential programs promote lifestyle changes and skill development, effective for those with poor social skills.
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.
Which assessment findings support a nurse's suspicion that a patient has been using inhalants?
- A. Pinpoint pupils and respiratory rate of 12 breaths per minute
- B. Perforated nasal septum and hypertension
- C. Drowsiness, euphoria, and constipation
- D. Nosebleed, muscle wasting, and impaired hearing
Correct Answer: D
Rationale: Inhalant use causes nosebleeds, muscle wasting, and sensory impairments like hearing loss.