Nokea
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats/min. The patient shouts, 'Snakes are crawling on my bed. I've got to get out of here.' What is the most accurate assessment of the situation?
- A. The patient is attempting to obtain attention by manipulating staff.
- B. The patient may have sustained a head injury before admission.
- C. The patient has symptoms of alcohol withdrawal delirium.
- D. The patient is having a recurrence of an acute psychosis.
Correct Answer: C
Rationale: Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency.
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Which statement most accurately describes substance addiction?
- A. A chronic, relapsing brain disease associated with craving and a lack of control over use of a substance.
- B. A disorder associated with tolerance to a substance as well as withdrawal symptoms if use is abruptly discontinued.
- C. Behaviors associated with habitual use of a substance for the single purpose of altering one's mood, emotion, or state of consciousness.
- D. A behavioral disorder associated with selected personality features.
Correct Answer: A
Rationale: Addiction involves a lack of control and craving, characteristic of a chronic brain disease.
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.
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.
In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats/min (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone. What is the priority outcome for this patient?
- A. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
- B. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department.
- C. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
- D. The patient will identify two community resources for the treatment of substance abuse by discharge.
Correct Answer: A
Rationale: Stabilizing vital signs is the priority for an opiate overdose.
A patient undergoing alcohol rehabilitation decides to accept disulfiram therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient?
- A. Avoid aged cheeses.
- B. Read labels of all liquid medications.
- C. Wear sunscreen and avoid bright sunlight.
- D. Maintain an adequate dietary intake of sodium.
- E. Avoid breathing fumes of paints, stains, and stripping compounds.
Correct Answer: B,E
Rationale: Disulfiram reacts with alcohol, so patients must avoid hidden alcohol sources like liquid medications and alcohol-laden fumes.