Level 3 - RNSG 2213 - Review for Exam 3
Ch. 19, 10, 21, 22, 12, 26, 27, 28
Answered + Rationales.
An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect
withdrawal symptoms to peak?
a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
c. About 0200 on hospital day 3 (72 hours after drinking stopped)
d. About 0200 on hospital day 4 (96 hours after drinking stopped) ✅- B
Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol
intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse
plans for the delivery of an infant who is:
a. jaundiced
b. dependent on alcohol
c. healthy but underweight
d. microcephalic and cognitively impaired ✅- D
Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first
trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder.
Alcohol use during pregnancy is not likely to produce the findings listed in the distracters.
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The
patient points to the Buck traction and screams, "Somebody tied me up with ropes." The patient
is experiencing:
a. illusion
b. delusion
c. hallucinations
d. hypnagogic phenomenon ✅- A
The patient is misinterpreting a sensory perception when seeing a noose instead of traction.
Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief.
,Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic
phenomena are sensory disturbances that occur between waking and sleeping.
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is
shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient
shouts, "Bugs are crawling on my bed. I've got to get out of here." What is the most accurate
assessment of the situation? The patient:
a. is attempting to obtain attention by manipulating staff.
b. may have sustained a head injury before admission.
c. has symptoms of alcohol withdrawal delirium.
d. is having a recurrence of an acute psychosis. ✅- C
Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal
delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head
injury, or functional psychosis.
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are
crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority
nursing diagnosis?
a. Ineffective airway clearance
b. Ineffective coping
c. Ineffective denial
d. Risk for injury ✅- D
The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for
injury. Safety is the nurse's priority. The scenario does not provide data to support the other
diagnoses
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds
are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which
medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine ✅- C
Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in
most regions because of their high therapeutic safety index and anticonvulsant properties.
,A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning
entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing
intervention has priority?
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit. ✅- C
One-on-one supervision is necessary to promote physical safety until sedation reduces the
patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety.
A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.
An alcohol-dependent individual says, "Drinking helps me cope with being a single parent."
Which response by the nurse would help the individual conceptualize the drinking more
objectively?
a. "Sooner or later, alcohol will kill you. Then what will happen to your children?"
b. "I hear a lot of defensiveness in your voice. Do you really believe this?"
c. "If you were coping so well, why were you hospitalized again?"
d. "Tell me what happened the last time you drank." ✅- D
The individual is rationalizing. The correct response will help the patient see alcohol as a cause
of the problems, not the solution. This approach can also help the patient become receptive to the
possibility of change. The incorrect responses directly confront and attack defenses against
anxiety that the patient still needs. They reflect the nurse's frustration with the patient.
A patient asks for information about 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." ✅- A
AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither
professional nor peer leaders are appointed.
Police bring a patient to the emergency department after an automobile accident. The patient is
ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %).
, Considering the relationship between behavior and blood alcohol level, which conclusion can the
nurse draw? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has recently ingested both alcohol and sedative drugs. ✅- B
A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %).
The fact that the patient is walking and talking shows a discrepancy between blood alcohol level
and expected behavior. It strongly suggests that the patient's body has become tolerant to the
drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture
would result. The blood alcohol level gives no information about the ingestion of other drugs.
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." Which defense mechanism is evident?
a. Rationalization
b. Introjection
c. Projection
d. Denial ✅- D
Minimizing one's drinking is a form of denial of alcoholism. The patient's own description
indicates that "social drinking" is not an accurate name for the behavior. Projection involves
blaming another for one's faults or problems. Rationalization involves making excuses.
Introjection involves taking a quality into one's own system.
A new patient in 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 a few drinks
in the evening." Which response by the nurse will help the patient view the drinking more
honestly?
a "I see," and use interested silence.
b. "I think you may be drinking more than you report."
c. "Being a social drinker involves having a drink or two once or twice a week."
d. "You describe drinking steadily throughout the day and evening. Am I correct?" ✅- D
The answer summarizes and validates what the patient reported but is accepting rather than
strongly confrontational. Defenses cannot be removed until healthier coping strategies are in
place. Strong confrontation does not usually take place so early in treatment.
Ch. 19, 10, 21, 22, 12, 26, 27, 28
Answered + Rationales.
An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect
withdrawal symptoms to peak?
a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
c. About 0200 on hospital day 3 (72 hours after drinking stopped)
d. About 0200 on hospital day 4 (96 hours after drinking stopped) ✅- B
Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol
intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse
plans for the delivery of an infant who is:
a. jaundiced
b. dependent on alcohol
c. healthy but underweight
d. microcephalic and cognitively impaired ✅- D
Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first
trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder.
Alcohol use during pregnancy is not likely to produce the findings listed in the distracters.
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The
patient points to the Buck traction and screams, "Somebody tied me up with ropes." The patient
is experiencing:
a. illusion
b. delusion
c. hallucinations
d. hypnagogic phenomenon ✅- A
The patient is misinterpreting a sensory perception when seeing a noose instead of traction.
Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief.
,Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic
phenomena are sensory disturbances that occur between waking and sleeping.
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is
shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient
shouts, "Bugs are crawling on my bed. I've got to get out of here." What is the most accurate
assessment of the situation? The patient:
a. is attempting to obtain attention by manipulating staff.
b. may have sustained a head injury before admission.
c. has symptoms of alcohol withdrawal delirium.
d. is having a recurrence of an acute psychosis. ✅- C
Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal
delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head
injury, or functional psychosis.
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are
crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority
nursing diagnosis?
a. Ineffective airway clearance
b. Ineffective coping
c. Ineffective denial
d. Risk for injury ✅- D
The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for
injury. Safety is the nurse's priority. The scenario does not provide data to support the other
diagnoses
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds
are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which
medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine ✅- C
Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in
most regions because of their high therapeutic safety index and anticonvulsant properties.
,A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning
entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing
intervention has priority?
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit. ✅- C
One-on-one supervision is necessary to promote physical safety until sedation reduces the
patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety.
A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.
An alcohol-dependent individual says, "Drinking helps me cope with being a single parent."
Which response by the nurse would help the individual conceptualize the drinking more
objectively?
a. "Sooner or later, alcohol will kill you. Then what will happen to your children?"
b. "I hear a lot of defensiveness in your voice. Do you really believe this?"
c. "If you were coping so well, why were you hospitalized again?"
d. "Tell me what happened the last time you drank." ✅- D
The individual is rationalizing. The correct response will help the patient see alcohol as a cause
of the problems, not the solution. This approach can also help the patient become receptive to the
possibility of change. The incorrect responses directly confront and attack defenses against
anxiety that the patient still needs. They reflect the nurse's frustration with the patient.
A patient asks for information about 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." ✅- A
AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither
professional nor peer leaders are appointed.
Police bring a patient to the emergency department after an automobile accident. The patient is
ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %).
, Considering the relationship between behavior and blood alcohol level, which conclusion can the
nurse draw? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has recently ingested both alcohol and sedative drugs. ✅- B
A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %).
The fact that the patient is walking and talking shows a discrepancy between blood alcohol level
and expected behavior. It strongly suggests that the patient's body has become tolerant to the
drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture
would result. The blood alcohol level gives no information about the ingestion of other drugs.
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." Which defense mechanism is evident?
a. Rationalization
b. Introjection
c. Projection
d. Denial ✅- D
Minimizing one's drinking is a form of denial of alcoholism. The patient's own description
indicates that "social drinking" is not an accurate name for the behavior. Projection involves
blaming another for one's faults or problems. Rationalization involves making excuses.
Introjection involves taking a quality into one's own system.
A new patient in 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 a few drinks
in the evening." Which response by the nurse will help the patient view the drinking more
honestly?
a "I see," and use interested silence.
b. "I think you may be drinking more than you report."
c. "Being a social drinker involves having a drink or two once or twice a week."
d. "You describe drinking steadily throughout the day and evening. Am I correct?" ✅- D
The answer summarizes and validates what the patient reported but is accepting rather than
strongly confrontational. Defenses cannot be removed until healthier coping strategies are in
place. Strong confrontation does not usually take place so early in treatment.
