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What nursing intervention should be included in the plan of care for a baby born to a drug-addicted mother?
- A. Swaddle the baby closely.
- B. Place the baby in a brightly lit area.
- C. Hold and rock the baby frequently.
- D. Place the baby in a busy part of the nursery for stimulation.
Correct Answer: A
Rationale: A baby born to a drug-addicted mother should be swaddled, placed in an area of low stimulation, and minimally handled.
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When a patient denies any problems related to addiction, what is the nurse's most therapeutic response?
- A. What do you call this hospitalization?
- B. How can anybody help you if you don't see a problem?
- C. Would your family agree that you have no problems?
- D. Can you think of any time your behavior created an unpleasant situation in your life?
Correct Answer: D
Rationale: When the patient denies that his behavior is problematic, the nurse should ask the patient to recount incidences when the behavior had unpleasant consequences.
The nurse assesses an alcoholic patient carefully for signs of withdrawal. How soon after cessation of alcohol intake do withdrawal symptoms usually appear?
- A. 3 hours
- B. 4 hours
- C. 5 hours
- D. 6 hours
Correct Answer: D
Rationale: Withdrawal signs can occur as early as 6 hours after cessation of alcohol intake and sometimes last for 3 to 5 days.
The nurse is performing an initial assessment on an alcoholic patient. Which of the following actions by the nurse would best ensure honest answers?
- A. Not asking personal questions
- B. Having a nonjudgmental attitude
- C. Including the family
- D. Promising the patient not to tell anyone
Correct Answer: B
Rationale: Maintaining a nonjudgmental attitude may reassure the patient and allow him to be more honest in his responses to the admission assessment.
What should the nurse do to decrease the patient's disorientation at night during the detoxification period?
- A. Place the patient in a room with another recovering patient.
- B. Instruct the patient to orient himself to his surroundings at bedtime.
- C. Wake the patient up every 4 hours to eat a small snack.
- D. Use nightlights and remove extra furniture from the room.
Correct Answer: D
Rationale: Use of nightlights and removing extra furniture that could be misidentified will reduce disorientation. The patient should not be woken up to eat, but if he is awake, small snacks can be offered. The nurse should orient the patient to his surroundings.
During the detoxification period, what does the nurse aim to achieve when designing interventions?
- A. Enroll the patient in Alcoholics Anonymous (AA).
- B. Keep the patient safe from aspiration and seizure.
- C. Help the patient interact in nonaddictive activities.
- D. Help the patient gain insight into the addiction.
Correct Answer: B
Rationale: Care for the addicted patient starts with detoxification and is focused on keeping the patient safe from the symptoms of withdrawal. Enrolling the patient in AA, helping the patient interact in nonaddictive activities, and helping the patient gain insight into the addiction would be part of the rehabilitation process.