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The client who reports drinking half a case of beer each day is admitted for detoxification. Which answer explains the onset of withdrawal symptoms 4 hours after last reported drink?
- A. The client will progress through detox faster than expected.
- B. Early onset of withdrawal symptoms indicates incorrect reporting of the time of last use.
- C. Three hours is the normal onset for withdrawal symptoms to begin.
- D. The withdrawal process will take about 24 hours from time of onset.
Correct Answer: B
Rationale: Alcohol withdrawal usually begins 6 hours after last drink. This client has incorrectly reported the time of last use. The withdrawal process from alcohol usually takes about 48 hours or more.
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Which of the following instructions should a nurse give to clients with opiate dependency who take methadone?
- A. Avoid driving for 3 hours after medication.
- B. Take vitamin substitutes.
- C. Maintain bed rest for 1 hour after medication.
- D. Wear a MedicAlert tag.
Correct Answer: D
Rationale: The nurse should instruct the client who takes methadone to tell healthcare providers or wear a MedicAlert tag in case the client needs a narcotic, tranquilizer, or barbiturate. Because methadone is a narcotic, lower dosages of other sedative drugs are necessary because the combination may potentiate their depressant action. It is not essential for client to avoid driving or to maintain bed rest after medication. Vitamin substitutes may not be required.
A client states, 'My father was an alcoholic so I am destined to be one too.' Which is the best response by the nurse?
- A. Children of alcoholics are more likely to become alcoholic.
- B. There is treatment available to prevent the trait of alcoholism.
- C. This is just a theory and has no basis of proof.
- D. Let's talk about how you can take control of your destiny.
Correct Answer: D
Rationale: Even with a possible genetic link to alcoholism, the individual remains in control of taking the first drink that triggers the metabolism of alcohol to THIQ. Every person is responsible for his or her own destiny and should receive encouragement to exercise that control. Children of alcoholics (COA) do have a greater likelihood of developing alcohol dependency. The only prevention of the trait of alcoholism is abstinence.
Which is the best nursing intervention to prevent a potential depressant action of methadone caused by mixing with another drug?
- A. Urine testing
- B. Provide only liquid form of methadone.
- C. Interview client prior to dosing.
- D. Assess vital signs.
Correct Answer: A
Rationale: The practice of testing the urine before providing methadone is one way of screening and eliminating those who are abusing the system and trying to potentiate the effects of the methadone by combining with another depressant. The methadone should be administered by a professional and supplied in a liquid form to avoid cheeking of the drug. Addictive clients are drug-seeking in nature and cannot be trusted to always be honest with drug use questioning and answers. Vital sign monitoring is not significant in the detection of alternate drug use.
The client who is experiencing alcohol withdrawal has a temperature of 100.6?°F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?
- A. Encourage the client to rest.
- B. Administer benzodiazepine as ordered.
- C. Monitor for any further changes.
- D. Provide emotional support.
Correct Answer: B
Rationale: The standardized symptom withdrawal flow sheet, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) as well as the Rule of One Hundreds are indicators of escalating withdrawal. The rise in these vital signs suggests the need for sedative medication. Monitoring hourly vital signs and further changes would be appropriate. Rest and emotional support can be helpful.
Which blood alcohol level (BAL) is associated with coma?
- A. 200 mg/dL
- B. 300 mg/dL
- C. 400 mg/dL
- D. 500 mg/dL
Correct Answer: C
Rationale: A BAL of 400 mg/dL is associated with coma. A BAL of 200 mg/dL is associated with staggering and poor control of emotions. A BAL of 300 mg/dL is associated with mental confusion and stupor. A BAL of 500 mg/dL is associated with respiratory depression and death.