NUR 253 Exam 4 Mental
Health
Comprehensive Test Bank -
50 Questions
Verified comprehensive
rationales.
,UNIT 9: SUBSTANCE-RELATED DISORDERS
(Questions 1-15)
Question 1
A nurse is assessing a client who is experiencing alcohol withdrawal. Which
symptom indicates the client is progressing to severe withdrawal (delirium
tremens)?
A. Fine tremors of both hands
B. Diaphoresis and tachycardia
C. Visual hallucinations and clouded consciousness
D. Nausea and vomiting
Correct Answer: C
Rationale: Delirium tremens (DTs) represents the most severe form of
alcohol withdrawal and is a medical emergency. It is characterized by
profound confusion, disorientation, visual or tactile hallucinations, severe
autonomic instability (hypertension, tachycardia), and fluctuating levels of
consciousness. Early withdrawal symptoms (options A, B, D) include tremors,
diaphoresis, nausea, and anxiety, typically occurring 6-24 hours after
,cessation. DTs usually begin 48-72 hours after the last drink and require
immediate medical intervention.
*Source: Halter, J.A. (2022). Varcarolis' Foundations of Psychiatric-Mental
Health Nursing (9th ed.). p. 412*
Question 2
A client is brought to the emergency department unresponsive with shallow
respirations of 6 breaths per minute and pinpoint pupils. Which action should
the nurse take first?
A. Start an IV line with normal saline
B. Administer naloxone (Narcan) intravenously
C. Prepare for endotracheal intubation
D. Obtain a urine toxicology screen
Correct Answer: B
Rationale: The classic triad of coma, respiratory depression (6
breaths/minute), and pinpoint (miotic) pupils is highly indicative of opioid
overdose. The priority intervention is to reverse the life-threatening
respiratory depression by administering the opioid antagonist naloxone
(Narcan). While establishing IV access (A) is necessary for medication
administration, obtaining access and giving naloxone is the priority.
, Intubation (C) may be required if the client does not respond to naloxone. The
toxicology screen (D) is important but not the priority in this emergency
situation.
*Source: Galen College of Nursing. (2023). NUR 253 Mental Health Nursing
Course Syllabus. Unit 9: Substance-Related Disorders*
Question 3
A nurse is caring for a client experiencing opioid withdrawal. Which
assessment finding should the nurse expect?
A. Sedation and respiratory depression
B. Pinpoint pupils and constipation
C. Yawning, rhinorrhea, and piloerection
D. Hypotension and bradycardia
Correct Answer: C
Rationale: Opioid withdrawal symptoms are essentially the opposite of
opioid effects. The client experiences autonomic hyperactivity including
yawning, rhinorrhea (runny nose), lacrimation (tearing), piloerection
(goosebumps), diarrhea, dilated pupils, tachycardia, hypertension, and muscle
aches. Options A, B, and D describe opioid intoxication or overdose effects
Health
Comprehensive Test Bank -
50 Questions
Verified comprehensive
rationales.
,UNIT 9: SUBSTANCE-RELATED DISORDERS
(Questions 1-15)
Question 1
A nurse is assessing a client who is experiencing alcohol withdrawal. Which
symptom indicates the client is progressing to severe withdrawal (delirium
tremens)?
A. Fine tremors of both hands
B. Diaphoresis and tachycardia
C. Visual hallucinations and clouded consciousness
D. Nausea and vomiting
Correct Answer: C
Rationale: Delirium tremens (DTs) represents the most severe form of
alcohol withdrawal and is a medical emergency. It is characterized by
profound confusion, disorientation, visual or tactile hallucinations, severe
autonomic instability (hypertension, tachycardia), and fluctuating levels of
consciousness. Early withdrawal symptoms (options A, B, D) include tremors,
diaphoresis, nausea, and anxiety, typically occurring 6-24 hours after
,cessation. DTs usually begin 48-72 hours after the last drink and require
immediate medical intervention.
*Source: Halter, J.A. (2022). Varcarolis' Foundations of Psychiatric-Mental
Health Nursing (9th ed.). p. 412*
Question 2
A client is brought to the emergency department unresponsive with shallow
respirations of 6 breaths per minute and pinpoint pupils. Which action should
the nurse take first?
A. Start an IV line with normal saline
B. Administer naloxone (Narcan) intravenously
C. Prepare for endotracheal intubation
D. Obtain a urine toxicology screen
Correct Answer: B
Rationale: The classic triad of coma, respiratory depression (6
breaths/minute), and pinpoint (miotic) pupils is highly indicative of opioid
overdose. The priority intervention is to reverse the life-threatening
respiratory depression by administering the opioid antagonist naloxone
(Narcan). While establishing IV access (A) is necessary for medication
administration, obtaining access and giving naloxone is the priority.
, Intubation (C) may be required if the client does not respond to naloxone. The
toxicology screen (D) is important but not the priority in this emergency
situation.
*Source: Galen College of Nursing. (2023). NUR 253 Mental Health Nursing
Course Syllabus. Unit 9: Substance-Related Disorders*
Question 3
A nurse is caring for a client experiencing opioid withdrawal. Which
assessment finding should the nurse expect?
A. Sedation and respiratory depression
B. Pinpoint pupils and constipation
C. Yawning, rhinorrhea, and piloerection
D. Hypotension and bradycardia
Correct Answer: C
Rationale: Opioid withdrawal symptoms are essentially the opposite of
opioid effects. The client experiences autonomic hyperactivity including
yawning, rhinorrhea (runny nose), lacrimation (tearing), piloerection
(goosebumps), diarrhea, dilated pupils, tachycardia, hypertension, and muscle
aches. Options A, B, and D describe opioid intoxication or overdose effects
