Nokea
When assessing a patient who has ingested flunitrazepam, what should the nurse expect?
- A. Acrophobia
- B. Hypothermia
- C. Hallucinations
- D. Anterograde amnesia
Correct Answer: D
Rationale: Flunitrazepam causes anterograde amnesia, disinhibition, and muscle relaxation.
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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.
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
- A. Disturbed sensory perception
- B. Ineffective coping
- C. Ineffective denial
- D. Risk for injury
Correct Answer: D
Rationale: Clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety has a higher priority.
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
- A. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
- B. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
- C. About 0200 on hospital day 3 (72 hours after drinking stopped)
- D. About 0200 on hospital day 4 (96 hours after drinking stopped)
Correct Answer: B
Rationale: Alcohol withdrawal usually begins 2 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.
While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care?
- A. Administration of naloxone (Narcan)
- B. Vitamin B12 and folate supplements
- C. Restoring nutritional integrity
- D. Prevention of seizures
- E. Reduction of fever
Correct Answer: D,E
Rationale: Hyperpyrexia and convulsions are life-threatening in methamphetamine overdose, making these priorities.
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.