NURS 1023 – ADVANCED ASSESMMENT TEST
QUESTIONS WITH COMPLETE SOLUTIONS
Which nursing diagnosis is the priority for a client experiencing alcohol withdrawal?
A. Risk for injury r/t central nervous system stimulation
B. Disturbed thought processes r/t tactile hallucinations
C. Ineffective coping r/t powerlessness over alcohol use
D. Ineffective denial r/t continued alcohol use despite negative consequences -
Answer - Answer: A. Risk for injury r/t central nervous system stimulation.
Rationale: the priority nursing diagnosis for a client experiencing alcohol withdrawal
should be risk for injury r/t central nervous system stimulation. Alcohol withdrawal
may include the following symptoms: curse tremors of hands, tongue, or eyelids;
nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood
pressure; anxiety; depressed mood; hallucinations; headache; and insomnia
The nurse evaluates the client's patient-controlled analgesia (PCA) pump and
notices 50 attempts within a 15 minute period. Which is the best rationale for assess
this client for substance addiction?
A. Narcotic pain medication is contraindicated for all clients with active substance
use disorders
B. Clients who are addicted to alcohol or benzodiazepines may develop cross-
tolerance to analgesics and require increased doses to achieve effective pain control
C. There is no need to assess the client for substance addiction. There is an obvious
PCA malfunction, because these clients have a higher pain tolerance
D. The client is experiencing alcohol withdrawal symptoms and needs accurate
assessment - Answer - Answer: B. Clients who are addicted to alcohol or
benzodiazepines may develop cross-tolerance to analgesics and require increased
doses to achieve effective pain control
Rationale: The nurse should assess the client for substance addiction, because
clients who are addicted to alcohol or bentos may have developed cross-tolerance to
analgesics and require increased doses to achieve effective pain control. Cross-
tolerance is exhibited when one drug results in a lessened response to another drug.
On the first day of a client's alcohol detoxification, which nursing intervention should
take priority?
A. Strongly encourage the client to attend 90 AA meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer orders chlordiazepoxide (Librium) in dosage according to protocol.
,D. Provide thiamin supplements to prevent Wenicke-Korsakoff syndrome. - Answer -
Answer: C. Administer orders chlordiazepoxide (Librium) in dosage according to
protocol.
Rationale: Priority nursing intervention for this client should be to administer ordered
chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a
benzodiazepine and is often used for medication-assisted therapy in alcohol
withdrawal to reduce life-threatening complications.
Which client statement indicated a knowledge deficit related to a substance use
disorder?
A. "Although it's legal, alcohol is one of the most widely abused drugs in our society"
B. "Tolerance to heroin develops quickly"
C. "Flashbacks form lysergic acid diethyl amide (LSD) use may reoccur
spontaneously."
D. Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless'' -
Answer - Answer: D. Marijuana is like smoking cigarettes. Everyone does it. It's
essentially harmless''
Rationale: The nurse should determine that the client has a knowledge deficit related
to substance use disorder when the client compares marijuana to smoking cigarettes
and claims it to be harmless. The evidence of research indicates that smoked
marijuana is harmful.
A lonely, depressed divorcée has been self-medicating with small amounts of
cocaine for the past year. Which term should a nurse use to best describe this
individual's situation?
A. Psychological addiction
B. Codependence
C. Substance induced disorder
D. Intoxication - Answer - Answer: A. Psychological addiction
Rationale: The nurse should use therm psychological addiction to best describe the
client's situation. A client is considered to be psychologically addicted to a substance
when there is an overwhelming desire to use a drug in order to produce pleasure
(feel better) or avoid discomfort.
Which term should a nurse use to describe the administration of a central nervous
system (CNS) depressant during alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Medication-assisted treatment - Answer - Answer: D. Medication-assisted
treatment
Rationale: Various medications have been used to decrease the intensity of
symptoms in an individual who is withdrawing from, or who is experiencing the
,effects of excessive use of, alcohol and other drugs. This is called medication-
assisted treatment.
A client diagnosed with chronic alcohol dependency is being discharged from an
inpatient treatment facility after detoxification. Which client outcome related to
Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with
the client during discharge teaching?
A. To immediately attend AA meetings at least weekly
B. To rely on an AA sponsor to help control alcohol cravings
C. To incorporate family in AA attendance
D. To seek appropriate deterrent medications through AA - Answer - Answer: A. To
immediately attend AA meetings at least weekly
Rationale: The most appropriate client outcome for the nurse to discuss during
discharge teaching is attending AA meetings at least weekly. AA is a major self-help
organization for the treatment of alcohol addiction. It accepts alcohol addiction as an
illness and promotes total abstinence as the only cure.
A client with a history of alcohol use disorder is brought to an emergency department
(ED) by family members who state that the client has had nothing to drink in the last
48 hours. When the nurse reports to the ED physician, which client sign or symptom
should be the nurse's first priority
A. Hearing and visual impairment
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale
D. Dehydration - Answer - Answer: B. Blood pressure of 180/100 mm Hg
Rationale: The nurse should recognize that high blood pressure is a symptom of
alcohol withdrawal syndrome and should promptly report this finding to the physician.
Complications associated with alcohol withdrawal syndrome may progress to alcohol
withdrawal delirium in about the second or third day following cessation of prolonged
alcohol use.
Which client statement demonstrates positive progress toward recovery from
substance abuse?
A. "I have completed detox and therefore am in control of my drug use."
B. "When I can't control my cravings, I will faithfully attend Narcotic Anonymous."
C. "As a church deacon, my focus will now be on spiritual renewal."
D. "Taking those pills got out of control. It cost me my job, marriage, and children." -
Answer - Answer: D. "Taking those pills got out of control. It cost me my job,
marriage, and children."
Rationale: A client who takes responsibility for the consequences of substance use
disorder or substance addiction is making positive progress toward recovery. This
would indicate completion of the first step of the a 12 step program (AA)
The nurse holds the hand of a client who is experiencing alcohol withdrawal. The
nurse is assessing for which condition?
, A. Emotional strength
B. Wernicke-Korsakoff syndrome
C. Tachycardia
D. Coarse tremors - Answer - Answer: D. Coarse tremors
Rationale: The nurse is most likely assessing the client for coarse tremors secondary
to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia,
transient hallucinations, depression, irritability, anxiety, elevated blood pressure,
sweating, tachycardia, malaise, and coarse tremors
The client presents with symptoms of alcohol withdrawal and states, "I haven't eaten
in three days." The nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28,
and T 97 F with dry mucous membranes and poor skin turgor. What should be the
priority nursing diagnosis?
A. Denial
B. Fluid volume excess
C. Imbalance nutrition: less than body requirements
D. Ineffective individual coping - Answer - Answer: C. Imbalance nutrition: less than
body requirements
Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced
nutrition: less than body requirements based upon the client's statement regarding
lack of nutritional intake for three days. The client is exhibiting signs and symptoms
of malnutrition, as well as alcohol withdrawal. The nurse should provide small,
frequent feedings of nonirritating foods.
A clients wife has been making excuses for her alcoholic husband's work absences.
In family therapy, she states, "His problems at work are my fault." Which response
by the nurse is therapeutic?
A. "Why do you assume responsibility for his behaviors
B. "I think you should start to confront his behavior"
C. "Your husband needs to deal with the consequences of his drinking"
D. "Do you understand what the term enabler means?" - Answer - Answer: C. "Your
husband needs to deal with the consequences of his drinking"
Rationale: The appropriate nursing response is to use confrontation with caring. The
nurse should understand that the client's wife may be in denial and enabling the
husbands behavior. Codependency is a typical behavior of spouses of alcoholics.
The nurse must help the wife through the stages of recovery beginning with Stage 1:
The survival stage in which the partner begins to let go of the denial that problems
exists.
Which medications would the nurse most likely administer to a client who has a
history of opiate withdrawal?
A. Haloperidol (Haldol) and acamprosate (Campare)
B. Naloxone (Narcan) and naltrexone (ReVia)
QUESTIONS WITH COMPLETE SOLUTIONS
Which nursing diagnosis is the priority for a client experiencing alcohol withdrawal?
A. Risk for injury r/t central nervous system stimulation
B. Disturbed thought processes r/t tactile hallucinations
C. Ineffective coping r/t powerlessness over alcohol use
D. Ineffective denial r/t continued alcohol use despite negative consequences -
Answer - Answer: A. Risk for injury r/t central nervous system stimulation.
Rationale: the priority nursing diagnosis for a client experiencing alcohol withdrawal
should be risk for injury r/t central nervous system stimulation. Alcohol withdrawal
may include the following symptoms: curse tremors of hands, tongue, or eyelids;
nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood
pressure; anxiety; depressed mood; hallucinations; headache; and insomnia
The nurse evaluates the client's patient-controlled analgesia (PCA) pump and
notices 50 attempts within a 15 minute period. Which is the best rationale for assess
this client for substance addiction?
A. Narcotic pain medication is contraindicated for all clients with active substance
use disorders
B. Clients who are addicted to alcohol or benzodiazepines may develop cross-
tolerance to analgesics and require increased doses to achieve effective pain control
C. There is no need to assess the client for substance addiction. There is an obvious
PCA malfunction, because these clients have a higher pain tolerance
D. The client is experiencing alcohol withdrawal symptoms and needs accurate
assessment - Answer - Answer: B. Clients who are addicted to alcohol or
benzodiazepines may develop cross-tolerance to analgesics and require increased
doses to achieve effective pain control
Rationale: The nurse should assess the client for substance addiction, because
clients who are addicted to alcohol or bentos may have developed cross-tolerance to
analgesics and require increased doses to achieve effective pain control. Cross-
tolerance is exhibited when one drug results in a lessened response to another drug.
On the first day of a client's alcohol detoxification, which nursing intervention should
take priority?
A. Strongly encourage the client to attend 90 AA meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer orders chlordiazepoxide (Librium) in dosage according to protocol.
,D. Provide thiamin supplements to prevent Wenicke-Korsakoff syndrome. - Answer -
Answer: C. Administer orders chlordiazepoxide (Librium) in dosage according to
protocol.
Rationale: Priority nursing intervention for this client should be to administer ordered
chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a
benzodiazepine and is often used for medication-assisted therapy in alcohol
withdrawal to reduce life-threatening complications.
Which client statement indicated a knowledge deficit related to a substance use
disorder?
A. "Although it's legal, alcohol is one of the most widely abused drugs in our society"
B. "Tolerance to heroin develops quickly"
C. "Flashbacks form lysergic acid diethyl amide (LSD) use may reoccur
spontaneously."
D. Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless'' -
Answer - Answer: D. Marijuana is like smoking cigarettes. Everyone does it. It's
essentially harmless''
Rationale: The nurse should determine that the client has a knowledge deficit related
to substance use disorder when the client compares marijuana to smoking cigarettes
and claims it to be harmless. The evidence of research indicates that smoked
marijuana is harmful.
A lonely, depressed divorcée has been self-medicating with small amounts of
cocaine for the past year. Which term should a nurse use to best describe this
individual's situation?
A. Psychological addiction
B. Codependence
C. Substance induced disorder
D. Intoxication - Answer - Answer: A. Psychological addiction
Rationale: The nurse should use therm psychological addiction to best describe the
client's situation. A client is considered to be psychologically addicted to a substance
when there is an overwhelming desire to use a drug in order to produce pleasure
(feel better) or avoid discomfort.
Which term should a nurse use to describe the administration of a central nervous
system (CNS) depressant during alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Medication-assisted treatment - Answer - Answer: D. Medication-assisted
treatment
Rationale: Various medications have been used to decrease the intensity of
symptoms in an individual who is withdrawing from, or who is experiencing the
,effects of excessive use of, alcohol and other drugs. This is called medication-
assisted treatment.
A client diagnosed with chronic alcohol dependency is being discharged from an
inpatient treatment facility after detoxification. Which client outcome related to
Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with
the client during discharge teaching?
A. To immediately attend AA meetings at least weekly
B. To rely on an AA sponsor to help control alcohol cravings
C. To incorporate family in AA attendance
D. To seek appropriate deterrent medications through AA - Answer - Answer: A. To
immediately attend AA meetings at least weekly
Rationale: The most appropriate client outcome for the nurse to discuss during
discharge teaching is attending AA meetings at least weekly. AA is a major self-help
organization for the treatment of alcohol addiction. It accepts alcohol addiction as an
illness and promotes total abstinence as the only cure.
A client with a history of alcohol use disorder is brought to an emergency department
(ED) by family members who state that the client has had nothing to drink in the last
48 hours. When the nurse reports to the ED physician, which client sign or symptom
should be the nurse's first priority
A. Hearing and visual impairment
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale
D. Dehydration - Answer - Answer: B. Blood pressure of 180/100 mm Hg
Rationale: The nurse should recognize that high blood pressure is a symptom of
alcohol withdrawal syndrome and should promptly report this finding to the physician.
Complications associated with alcohol withdrawal syndrome may progress to alcohol
withdrawal delirium in about the second or third day following cessation of prolonged
alcohol use.
Which client statement demonstrates positive progress toward recovery from
substance abuse?
A. "I have completed detox and therefore am in control of my drug use."
B. "When I can't control my cravings, I will faithfully attend Narcotic Anonymous."
C. "As a church deacon, my focus will now be on spiritual renewal."
D. "Taking those pills got out of control. It cost me my job, marriage, and children." -
Answer - Answer: D. "Taking those pills got out of control. It cost me my job,
marriage, and children."
Rationale: A client who takes responsibility for the consequences of substance use
disorder or substance addiction is making positive progress toward recovery. This
would indicate completion of the first step of the a 12 step program (AA)
The nurse holds the hand of a client who is experiencing alcohol withdrawal. The
nurse is assessing for which condition?
, A. Emotional strength
B. Wernicke-Korsakoff syndrome
C. Tachycardia
D. Coarse tremors - Answer - Answer: D. Coarse tremors
Rationale: The nurse is most likely assessing the client for coarse tremors secondary
to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia,
transient hallucinations, depression, irritability, anxiety, elevated blood pressure,
sweating, tachycardia, malaise, and coarse tremors
The client presents with symptoms of alcohol withdrawal and states, "I haven't eaten
in three days." The nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28,
and T 97 F with dry mucous membranes and poor skin turgor. What should be the
priority nursing diagnosis?
A. Denial
B. Fluid volume excess
C. Imbalance nutrition: less than body requirements
D. Ineffective individual coping - Answer - Answer: C. Imbalance nutrition: less than
body requirements
Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced
nutrition: less than body requirements based upon the client's statement regarding
lack of nutritional intake for three days. The client is exhibiting signs and symptoms
of malnutrition, as well as alcohol withdrawal. The nurse should provide small,
frequent feedings of nonirritating foods.
A clients wife has been making excuses for her alcoholic husband's work absences.
In family therapy, she states, "His problems at work are my fault." Which response
by the nurse is therapeutic?
A. "Why do you assume responsibility for his behaviors
B. "I think you should start to confront his behavior"
C. "Your husband needs to deal with the consequences of his drinking"
D. "Do you understand what the term enabler means?" - Answer - Answer: C. "Your
husband needs to deal with the consequences of his drinking"
Rationale: The appropriate nursing response is to use confrontation with caring. The
nurse should understand that the client's wife may be in denial and enabling the
husbands behavior. Codependency is a typical behavior of spouses of alcoholics.
The nurse must help the wife through the stages of recovery beginning with Stage 1:
The survival stage in which the partner begins to let go of the denial that problems
exists.
Which medications would the nurse most likely administer to a client who has a
history of opiate withdrawal?
A. Haloperidol (Haldol) and acamprosate (Campare)
B. Naloxone (Narcan) and naltrexone (ReVia)
