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The nurse is caring for a patient with alcohol dependence who has been admitted to the hospital with chest pain. Twenty-four hours after admission, the patient becomes very tremulous and anxious. Which of the following actions should the nurse implement?
- A. Insert an IV line and infuse fluids.
- B. Promote oral intake to 3000 mL/day.
- C. Provide a quiet, well-lit environment.
- D. Administer opioids to provide sedation.
Correct Answer: C
Rationale: The patient's symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help to decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible.
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A patient who is alcohol-intoxicated must undergo emergency surgery for abdominal trauma. Which of the following should the nurse anticipate when caring for the patient in the perioperative period?
- A. An increased dose of the general anaesthetic medication
- B. Frequent monitoring for bleeding and respiratory complications
- C. Development of withdrawal symptoms within a few hours after surgery
- D. Stimulation every hour to prevent prolonged postoperative sedation
Correct Answer: B
Rationale: Patients who are intoxicated at the time of surgery are at increased risk for problems with bleeding and respiratory complications such as aspiration. In an intoxicated patient, a lower dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is likely to occur later in the postoperative course because the medications used for anesthesia, sedation, and pain will delay withdrawal symptoms. The patient should be monitored frequently for oversedation but does not need to be stimulated.
The nurse is caring for an adult patient who is experiencing acute intoxication. Which of the following time frames should the nurse anticipate for the resolution of acute intoxication responses?
- A. 4 hours
- B. 12 hours
- C. 24 hours
- D. 48 hours
Correct Answer: C
Rationale: Intoxication responses usually last less than 24 hours and are directly related to the ingestion of psychoactive substances.
During physical assessment of a patient who has sinus headaches, the nurse finds nasal sores and necrosis of the nasal septum. Patient use of which of the following substances should the nurse include in the assessment?
- A. Heroin
- B. Cocaine
- C. Tobacco
- D. Marijuana
Correct Answer: B
Rationale: When cocaine is inhaled, it causes ischemia of the nasal septum, leading to nasal sores and necrosis. These symptoms are not associated with the use of heroin, tobacco, or marijuana.
The nurse is caring for a patient admitted to hospital with chest pain who is a pack-a-day smoker and tells the nurse, 'I am just not ready to quit smoking yet.' Which of the following responses is the most appropriate?
- A. This would be a really good time to quit.
- B. Your smoking is the cause of your chest pain.
- C. Do you think that smoking has caused any health problems?
- D. Are you familiar with the various nicotine replacement options?
Correct Answer: C
Rationale: The patient is in the precontemplation stage of change, and the nurse's role is to assist the patient in identifying motivators to quitting. The current Clinical Practice Guidelines indicate that the nurse should ask the patient to identify any negative consequences from smoking. The responses 'This would be a really good time to quit.' and 'Your smoking is the cause of your chest pain.' express judgmental feelings by the nurse and are not likely to motivate the patient. Providing information about the various nicotine replacement options would be appropriate for a patient who has expressed a desire to quit smoking.
All the following medications are ordered for a patient admitted with a blood alcohol concentration of 0.8 mg%. Which of the following should the nurse administer first?
- A. Thiamine 100 mg IV daily
- B. Lorazepam 1 mg SL as needed
- C. Folic acid 0.4 mg PO daily
- D. Dextrose 5% in water over 8 hours
Correct Answer: A
Rationale: Thiamine is given to all patients with alcohol intoxication to prevent Wernicke's encephalopathy. Because Wernicke's encephalopathy can be precipitated by the administration of glucose solutions, the thiamine should be given before (or concurrently with) the 5% dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated blood alcohol concentration (BAC). Folic acid also may be administered but is not as important as thiamine.