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Which assessment findings will the nurse expect in an individual who has just injected heroin?
- A. Anxiety, restlessness, paranoid delusions
- B. Heightened sexuality, insomnia, euphoria
- C. Muscle aching, dilated pupils, tachycardia
- D. Drowsiness, constricted pupils, slurred speech
Correct Answer: D
Rationale: Heroin, a CNS depressant, causes drowsiness, constricted pupils, and slurred speech.
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A patient asks for information about the goals of Alcoholics Anonymous (AA). Which is the nurse's best response?
- A. It is a self-help group with the goal of sobriety.'
- B. It is a form of group therapy led by a psychiatrist.'
- C. It is a group that learns about drinking from a group leader.'
- D. It is a network that advocates strong punishment for drunk drivers.'
Correct Answer: A
Rationale: AA is a peer support group for recovering alcoholics with the goal of maintaining sobriety.
Select the nursing intervention necessary after administering naloxone to a patient experiencing an opiate overdose.
- A. Monitor the airway and vital signs every 15 minutes.
- B. Insert a nasogastric tube and test gastric pH.
- C. Treat hyperpyrexia with cooling measures.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Naloxone reverses CNS depression, but monitoring is needed as narcotics outlast the antagonist.
A patient admitted to an alcoholism rehabilitation program says, 'I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening.' The patient is using which defense mechanism?
- A. Rationalization
- B. Introjection
- C. Projection
- D. Denial
Correct Answer: D
Rationale: Minimizing drinking is a form of denial of alcoholism.
A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling?
- A. Conveying understanding that pressures associated with nursing practice underlie substance abuse
- B. Pointing out that work problems are the result, but not the cause, of substance abuse
- C. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing
- D. Providing health teaching about stress management
Correct Answer: A
Rationale: Enabling denies the seriousness of the problem or shifts responsibility from the individual.
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.