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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.
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Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction?
- A. Methadone
- B. Bromocriptine
- C. Disulfiram
- D. Naltrexone
Correct Answer: D
Rationale: Naltrexone blocks opioid action and reduces alcohol craving, useful for both addictions.
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.
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.
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.
The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?
- A. Consider each disorder primary and provide simultaneous treatment.
- B. The person will benefit from treatment in a residential treatment facility.
- C. Withdraw the person from cannabis, and then treat the schizophrenia.
- D. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
Correct Answer: A
Rationale: Dual diagnosis guidelines suggest treating both substance and psychiatric disorders as primary with simultaneous treatments.