Nokea
A patient comes to an outpatient appointment obviously intoxicated. The nurse should implement what intervention?
- A. Exploring the patient's reasons for drinking today
- B. Arranging admission to an inpatient psychiatric unit
- C. Coordinating emergency admission to a detoxification unit
- D. Telling the patient, 'We cannot see you today because you've been drinking'
Correct Answer: D
Rationale: Therapy cannot be conducted with an intoxicated patient; rescheduling is appropriate.
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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.
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.
A new patient in 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 a few drinks in the evening.' Which response by the nurse will help the patient view the drinking more honestly?
- A. I see,' and use interested silence.
- B. I think you may be drinking more than you report.'
- C. Being a social drinker involves having a drink or two once or twice a week.'
- D. You describe drinking steadily throughout the day and evening. Am I correct?'
Correct Answer: D
Rationale: This response summarizes and validates the patient's report in an accepting manner, encouraging honesty.
Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective?
- A. Is abstinent for 10 days and states, 'I can maintain sobriety one day at a time.' Spoke with employer, who is willing to allow the patient to return to work in 3 weeks.
- B. Is abstinent for 15 days and states, 'My problems are under control.' Plans to seek a new job where coworkers will not know history.
- C. Attends AA daily; states many of the members are 'real' alcoholics and says, 'I may be able to help some of them find jobs at my company.'
- D. Is abstinent for 21 days and says, 'I know I can't handle more than one or two drinks in a social setting.'
Correct Answer: A
Rationale: This reflects AA principles and practical steps toward sobriety, indicating treatment effectiveness.
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.