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.
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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.
A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
- A. Substance abuse
- B. Substance addiction
- C. Substance intoxication
- D. Recreational use of a social drug
Correct Answer: B
Rationale: Nicotine addiction is indicated by compulsive use, craving, tolerance, and withdrawal symptoms.
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 while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?
- A. Monoamine oxidase inhibitor, such as phenelzine
- B. Phenothiazine, such as thioridazine
- C. Benzodiazepine, such as lorazepam
- D. Narcotic analgesic, such as morphine
Correct Answer: C
Rationale: Benzodiazepines are the drugs of choice for alcohol withdrawal delirium due to their high therapeutic safety index and anticonvulsant properties.
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who presents with what related characteristic?
- A. Jaundice
- B. Dependent on alcohol
- C. Healthy but underweight
- D. Facial abnormalities and cognitive impairment
Correct Answer: D
Rationale: Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder.
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