Nokea
Which assessment findings best correlate to the withdrawal from central nervous system depressants?
- A. Dilated pupils, tachycardia, elevated blood pressure, elation
- B. Labile mood, lack of coordination, fever, drowsiness
- C. Nausea, vomiting, diaphoresis, anxiety, tremors
- D. Excessive eating, constipation, headache
Correct Answer: C
Rationale: CNS depressant withdrawal symptoms resemble a flulike state with seizures possible.
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Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective?
- A. Is abstinent for 10 days and states, 'I can maintain sobriety one day at a time.' Spoke with employer, who is willing to allow the patient to return to work in 3 weeks.
- B. Is abstinent for 15 days and states, 'My problems are under control.' Plans to seek a new job where coworkers will not know history.
- C. Attends AA daily; states many of the members are 'real' alcoholics and says, 'I may be able to help some of them find jobs at my company.'
- D. Is abstinent for 21 days and says, 'I know I can't handle more than one or two drinks in a social setting.'
Correct Answer: A
Rationale: This reflects AA principles and practical steps toward sobriety, indicating treatment effectiveness.
A graduate nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident?
- A. Changing employment after only several months
- B. Seeking to be assigned as a medication nurse
- C. Frequent socializes with unit staff after work
- D. Recent graduate
Correct Answer: B
Rationale: Seeking access to medications is a drug-seeking behavior.
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
- A. Make physical contact by frequently touching the patient.
- B. Offer intellectual activities requiring concentration.
- C. Avoid manipulation by denying the patient's requests.
- D. Observe for depression and suicidal ideation.
Correct Answer: D
Rationale: Rebound depression is common in CNS stimulant withdrawal, requiring monitoring for suicide risk.
Which assessment findings support a nurse's suspicion that a patient has been using inhalants?
- A. Pinpoint pupils and respiratory rate of 12 breaths per minute
- B. Perforated nasal septum and hypertension
- C. Drowsiness, euphoria, and constipation
- D. Nosebleed, muscle wasting, and impaired hearing
Correct Answer: D
Rationale: Inhalant use causes nosebleeds, muscle wasting, and sensory impairments like hearing loss.
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled 'lorazepam.' What is the nurse's first action?
- A. Test reflexes.
- B. Check pupils.
- C. Initiate vomiting.
- D. Establish a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority for an unconscious patient to prevent aspiration.