Chapter 11: Substance Use Disorders in Acute Care Harding: Lewis’s Medical-Surgical Nursing, 12th Edition

Test Bank For Lewis's Medical-Surgical Nursing, 12th Edition by Mariann M. Harding, Jeffrey Kwong, Debra Hagler Chapter 11: Substance Use Disorders in Acute Care Harding: Lewis’s Medical-Surgical Nursing, 12th Edition MULTIPLE CHOICE 1. The nurse plans postoperative care for a patient who smokes cannabis daily at home. Which goal would the nurse include in the plan of care? A. Promote sleep. B. Manage diarrhea. C. Treat forsore throat. D. Provide environmental stimulation. ANS: A Insomnia is a characteristic of cannabis withdrawal. Other symptoms include irritability, insomnia, anorexia, anger, anxiety, and restlessness. Diarrhea, sore throat, and lethargy are not symptoms associated with cannabis withdrawal. 2. A young adult patient scheduled for an annual physical examination arrives in the clinic smelling of tobacco and carrying an e-cigarette cartridge. Which action would the nurse plan to take? A. Urge the patient to quit vaping as soon as possible. B. Wait for the patient to start a discussion about vaping. C. Avoid confronting the patient about vaping at this time. D. Explain that the “cold turkey” method is most effective to stop vaping. ANS: A Current national guidelines indicate that health care professionals should urge patients who smoke or vape tobacco to quit smoking at every encounter. The other actions will not help decrease the patient‘s health risks. 3. A patient admitted to the hospital after an automobile crash is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11%). Which action would the nurse take? A. Restrict oral and intravenous fluids. B. Maintain the patient on NPO status. C. Monitor for tremors and diaphoresis. D. Administer acetaminophen for headache. ANS: C The patient‘s assessment data indicate probable physiologic dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, tremors, and sweating, which could be life threatening. Acetaminophen is not recommended because it is metabolized by the liver. Alcohol has a dehydrating effect so fluids should not be restricted and there is no indication that the patient should be NPO. 4. An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing emergency surgery. Which action would the nurse expect to be included in the interprofessional plan of care? A. Increased doses of the general anesthetic medication B. Stimulation hourly to prevent prolonged postoperative sedation C. Frequent monitoring for bleeding and respiratory complications D. Begin interventions to prevent withdrawal symptoms within 2 hours ANS: C Patients who are intoxicated at the time of surgery are at increased risk for problems with bleeding and respiratory complications such as aspiration. In an intoxicated patient, a lower dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is likely to occur later in the postoperative course because the medications used for anesthesia, sedation, and pain will delay withdrawal symptoms. The patient should be monitored frequently for oversedation but does not need to be stimulated. 5. A patient with alcohol dependence is admitted to the hospital with back pain after a fall. Twenty-four hours after admission, the patient becomes anxious and has tremors. Which action would the nurse take? A. Insert an IV line and infuse fluids. B. Administer opioids to provide sedation. C. Provide a quiet and well-lit environment. D. Encourage increased liquid and food intake. ANS: C The patient‘s symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated or underfed. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible as they provide additional stimulation and increase the risk for infection. 6. A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use? A. “I am older and wiser now, and I can change my drinking behavior.” B. “Alcohol has never bothered my stomach before. I think Ihave the flu.” C. “People say that I drink too much, but Ifeel pretty good most of the time.” D. “My drinking is affecting mystomach, but medication will help me feel better.” ANS: A The statement “I am older and wiser now, and I can change my drinking behavior” indicates the patient expresses willingness to stop alcohol use and an initial commitment to changing alcohol intake behaviors. In the remaining statements, the patient recognizes that alcohol use is the reason for the gastritis but is not yet willing to make a change. 7. A patient who uses e-cigarette tobacco products daily develops tachycardia and irritability on the second day after abdominal surgery. Which action would the nurse take? A. Escort the patient outside where vaping is allowed. B. Request a prescription for a nicotine replacement agent. C. Tell the patient to calm down and not to think about vaping. D. Ask the patient‘s family to bring in chewable tobacco products. ANS: B Nicotine replacement agents should be prescribed for patients who use tobacco products and are hospitalized to avoid withdrawal symptoms. Allowing the patient to smoke or use other tobacco products encourages ongoing tobacco use. Telling the patient to calm down will not relieve withdrawal symptoms. 8. A patient who is admitted to the hospital for wound debridement admits to using fentanyl (Sublimaze) illegally. Which withdrawal signs would the nurse expect? A. Seizures B. Vomiting C. Lethargy D. Hallucinations ANS: B Symptoms of opioid withdrawal include gastrointestinal symptoms such as nausea, vomiting, and diarrhea. The other symptoms are seen during withdrawal from other substances such as alcohol, sedative-hypnotics, or stimulants. 9. A newly admitted patient reports waking frequently during the night. The nurse observes the patient wearing a nicotine patch on the right upper arm. Which action should the nurse take first? A. Question the patient about use of the patch at night. B. Suggest that the patient avoid caffeine in the afternoon and evening. C. Ask the health care provider about prescribing a sedative drug for nighttime use. D. Remind the patient that the benefits of the patch outweigh the short-term insomnia. ANS: A Insomnia can occur when nicotine patches are used all night. This can be resolved by removing the patch in the evening. The other actions may be helpful in improving the patient‘s sleep, but the initial action should be to ask about nighttime use of the patch and suggest removing the patch at bedtime. 10. During physical assessment of a patient who has frequent nosebleeds, the nurse finds nasal sores and necrosis of the nasal septum. The nurse would ask the patient specifically about the use of which drug? A. Heroin B. Cocaine C. Tobacco D. Marijuana ANS: B Inhaled cocaine causes ischemia of the nasal septum, leading to nasal sores and necrosis. These symptoms are not associated with the use of heroin, tobacco, or marijuana. 11. A patient admitted with shortness of breath and chest pain who is a pack-a-day smoker tells the nurse, “I am just not ready to quit smoking yet.” Which response by the nurse addresses the patient‘s stage of change? A. “This would be a good time for you to quit.” B. “Yoursmoking isthe cause of your chest pain.” C. “Are you familiar with nicotine replacement products?” D. “What health problems do you think smoking has caused?” ANS: D The patient is in the precontemplation stage of change, and the nurse‘s role is to assist the patient to become motivated to quit. The current Clinical Practice Guidelines indicate that the nurse should ask the patient to identify any negative consequences from smoking. The responses “This would be a really good time to quit” and “Your smoking is the cause of your chest pain” express judgmental feelings by the nurse and are not likely to motivate the patient. Providing information about the various nicotine replacement options would be appropriate for a patient who has expressed a desire to quit smoking. 12. A patient who is disoriented and agitated comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg, heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important? A. Monitor the patient‘s electrocardiogram. B. Reorient the patient at frequent intervals. C. Keep the patient in a quiet and darkened room. D. Obtain a health history including prior drug use. ANS: A The priority is to ensure physiologic stability given that methamphetamine use can lead to complications such as myocardial infarction. The other actions are also appropriate but are not of as high a priority. 13. A 73-yr-old patient is admitted with pancreatitis. Which tool would be the nurse choose to use during the admission assessment? A. Mini-Mental State Examination B. Drug Abuse Screening Test (DAST-10) C. Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) D. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) ANS: C Because alcohol use is a common factor associated with the development of pancreatitis, it will be important to screen for alcohol use using a validated screening questionnaire. The SMAST-G is a short-form alcoholism screening instrument tailored specifically to the needs of the older adult. If the patient scores positively on the SMAST-G, then the CIWA-Ar would be a useful tool for determining treatment. The DAST-10 provides more general information about substance use. The Mini-Mental State Examination screens for cognitive impairment. 14. An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a refill of the prescription 1 month before the alprazolam should need to be refilled. Which response would the nurse provide? A. “The prescription cannot be refilled for another month. What happened to all of your pills?” B. “Do you have muscle cramps and tremorsif you don‘t take the medication frequently?” C. “Iwill ask the health care provider to prescribe more pills, but you will not be able to have them until next month.” D. “I am concerned that you may be overusing those. I‘ll make an appointment for you with the health care provider.” ANS: D The patient should be assessed for problems that are causing overuse of alprazolam, such as anxiety or memory loss. The other responses by the nurse will not allow for the needed assessment and possible referral for support services or treatment of drug dependence. 15. A patient who has inhaled cocaine presents to the emergency department with palpitations and shortness of breath. Which action would the nurse take first? A. Infuse normal saline. B. Check oxygen saturation. C. Draw blood for drug screening. D. Obtain a 12-lead echocardiogram (ECG). ANS: B The priority here is to ensure that oxygenation is adequate. The other actions also should be accomplished as soon as possible but are not the first priority. 16. The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and trying to jump from a third-story window. Which patient problem would the nurse assign as the highest priority? A. Anxiety B. Risk for injury C. Substance use D. Difficulty coping ANS: B Although all the diagnoses may be appropriate for the patient, the highest priority is to address the patient‘s immediate risk for injury. 17. A 25-yr-old patient comes to the emergency department with severe chest pain and agitation. Which action would the nurse take first? A. Ask about habitual use of stimulant drugs. B. Assess orientation to person, place, and time. C. Check blood pressure, pulse, and respirations. D. Start an IV for administering antipsychotic drugs. ANS: C The patient has symptoms consistent with the use of cocaine or amphetamines and is at risk for fatal tachydysrhythmias or complications of hypertension such as stroke or myocardial infarction. The nurse also will ask about drug use and assess orientation, but these are not the priority actions. Antipsychotics may be used if the patient develops hallucinations. 18. A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18%. After reviewing the prescribed medications, which drug would the nurse administer first? A. Oral multivitamin daily B. Thiamine (vitamin B1) 100 mg daily C. Lorazepam (Ativan) 1 mg as needed D. Folic acid (vitamin B9) 0.4 mg daily ANS: B Thiamine is given to all patients with alcohol intoxication to prevent Wernicke-Korsakoff syndrome. Because Wernicke-Korsakoff syndrome can be precipitated by the administration of glucose solutions, thiamine should be given before or concurrently with a dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated BAC but may be used later for withdrawal symptoms. Folic acid and multivitamins may also be administered but are not as urgent as thiamine. 19. Which information is most urgent for the nurse to report to the health care provider about a patient who has been using varenicline (Chantix)? A. The patient reports headaches that occur almost daily. B. The patient reports new-onset sadness and depression. C. The patient continues to smoke a few e-cigarettes every day. D. The patient says, “I have decided that I am not ready to quit.” ANS: B Adverse effects of varenicline include depression and attempted suicide, which require immediate assessment and discontinuation of the drug. The other information will also be reported, but it does not indicate a life-threatening problem associated with the medication. 20. A patient who has a history of ongoing opioid use is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication would the nurse expect to administer? A. Naloxone B. Diazepam (Valium) C. Clonidine (Catapres) D. Methadone (Dolophine) ANS: A The patient‘s assessment indicates an opioid overdose, and naloxone should be given to prevent respiratory arrest. The other medications may be used to decrease symptoms associated with opioid withdrawal but would not be appropriate for an overdose. 21. After receiving change-of-shift report on 4 patients who are undergoing substance use treatment, which patient would the nurse assess first? A. A patient who has just arrived for alcohol use treatment and states that the last drink was 2 hours ago. B. A patient receiving treatment for cocaine addiction who is irritable with a pulse rate of 112 beats/min. C. A patient who is agitated and nauseated while withdrawing from heroin. D. A patient who last used benzodiazepines 4 days ago and has new tremors. ANS: D The patient‘s tremors indicate risk for seizures and possible cardiac/respiratory arrest, which can occur with withdrawal from sedative-hypnotics. The greatest risk for these complications occurs 3 to 5 days after stopping the drug. Opioid and stimulant withdrawal are uncomfortable but not life threatening. Symptoms of alcohol withdrawal do not occur until 4 to 6 hours after the last drink. 22. After the nurse receives report, which patient would the nurse assess first? A. Patient with a history of daily alcohol use who reports insomnia and diaphoresis B. Patient who is having hallucinations and extreme anxiety after the use of marijuana C. Patient who has a respiratory rate of 14 after taking an overdose of oxycodone (OxyContin) D. Patient with cocaine intoxication use who has an irregular heart rate of 142 beats/min ANS: D Because the patient with cocaine use has symptoms suggestive of a dysrhythmia, this patient should be assessed immediately. The other patients should also be seen as soon as possible, but their clinical manifestations do not suggest that life-threatening complications may be occurring. 23. Which nursing activity can the nurse delegate to assistive personnel (AP) who are working in a family practice clinic? A. Make referrals to community substance use treatment centers. B. Teach patients about the use of nicotine replacement products. C. Obtain patient histories about alcohol, tobacco, and other substance use. D. Administer and score the Alcohol Use Disorders Identification Test (AUDIT). ANS: D No clinical judgment is needed to administer the AUDIT, which is a written questionnaire that is given to patients for self-administration and scored based on patient answers. Making appropriate referrals, patient teaching, and obtaining a patient history all require critical thinking and RN education and scope of practice.