Nokea
A patient was admitted 1 day ago with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, 'Somebody tied me up with ropes.' The patient's response is described by what term?
- A. An illusion
- B. A delusion
- C. Hallucinations
- D. Hypnagogic phenomenon
Correct Answer: A
Rationale: The patient is misinterpreting a sensory perception when seeing a rope instead of traction. Illusions are common in early withdrawal from alcohol.
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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 use says, 'Drinking helps me cope with being a single parent.' Which response by the nurse would help the individual conceptualize the drinking more objectively?
- A. Sooner or later, alcohol will kill you. Then what will happen to your children?'
- B. I hear a lot of defensiveness in your voice. Do you really believe this?'
- C. If you were coping so well, why were you hospitalized again?'
- D. Tell me what happened the last time you drank.'
Correct Answer: D
Rationale: This response helps the patient see alcohol as a cause of problems, not a solution, and encourages receptivity to change.
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.
A patient is admitted in a comatose state after ingesting five capsules of lorazepam. A friend of the patient says, 'Often my friend drinks, along with taking more of the drug than is prescribed.' What is the effect of the use of alcohol with this drug?
- A. The drug's metabolism is stimulated.
- B. The drug's effect is diminished.
- C. A synergistic effect occurs.
- D. There is no effect.
Correct Answer: C
Rationale: Alcohol and lorazepam, both CNS depressants, have synergistic effects, potentiating each other.
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.