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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.
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The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?
- A. Consider each disorder primary and provide simultaneous treatment.
- B. The person will benefit from treatment in a residential treatment facility.
- C. Withdraw the person from cannabis, and then treat the schizophrenia.
- D. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
Correct Answer: A
Rationale: Dual diagnosis guidelines suggest treating both substance and psychiatric disorders as primary with simultaneous treatments.
Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
- A. Have you ever had blackouts?'
- B. When did you have your last drink?'
- C. Has drinking caused you any problems?'
- D. When did you decide to seek treatment?'
Correct Answer: B
Rationale: Knowing the last drink time is critical to anticipate withdrawal symptoms.
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
- A. Check the patient every 15 minutes.
- B. Rigorously encourage fluid intake.
- C. Provide one-on-one supervision.
- D. Keep the room dimly lit.
Correct Answer: C
Rationale: One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror.
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.
Select the nursing intervention necessary after administering naloxone to a patient experiencing an opiate overdose.
- A. Monitor the airway and vital signs every 15 minutes.
- B. Insert a nasogastric tube and test gastric pH.
- C. Treat hyperpyrexia with cooling measures.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Naloxone reverses CNS depression, but monitoring is needed as narcotics outlast the antagonist.