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Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
- A. Have you ever had blackouts?'
- B. When did you have your last drink?'
- C. Has drinking caused you any problems?'
- D. When did you decide to seek treatment?'
Correct Answer: B
Rationale: Knowing the last drink time is critical to anticipate withdrawal symptoms.
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A patient is admitted in a comatose state after ingesting five capsules of lorazepam. A friend of the patient says, 'Often my friend drinks, along with taking more of the drug than is prescribed.' What is the effect of the use of alcohol with this drug?
- A. The drug's metabolism is stimulated.
- B. The drug's effect is diminished.
- C. A synergistic effect occurs.
- D. There is no effect.
Correct Answer: C
Rationale: Alcohol and lorazepam, both CNS depressants, have synergistic effects, potentiating each other.
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.
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 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.
An adult in the emergency department states, 'I feel restless. Everything I look is wavy. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind.' Vital signs are slightly elevated. The nurse should suspect what triggered these reports?
- A. Cocaine overdose
- B. Schizophrenic episode
- C. Phencyclidine (PCP) intoxication
- D. Lysergic acid diethylamide (LSD) ingestion
Correct Answer: D
Rationale: LSD ingestion causes synesthesia, depersonalization, and concerns about losing sanity.