HESI TEST BANK MENTAL HEALTH TEST
CHAPTER 19 SUBSTANCE RELATED AND
ADDICTIVE DISORDER QUESTIONS WITH
WELL EXPLAINED ANSWERS(WITH REF) A
GRADE| UPDATE 2024 REAL EXAM!!
Chapter 19: Substance-Related and Addictive Disorders Test Bank
MULTIPLE CHOICE
1. 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)
ANS: 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.
DIF: Cognitive Level: Application REF: Pages: 336-367
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. 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
ANS: 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.
DIF: Cognitive Level: Application REF: Page: 363
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
, 3. 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
, ANS: 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.
DIF: Cognitive Level: Comprehension REF: Page: 367
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. 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.
ANS: 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.
DIF: Cognitive Level: Application REF: Pages: 366-368
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. 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
ANS: 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.
DIF: Cognitive Level: Analysis REF: Pages: 372-
373 TOP: Nursing Process: Diagnosis| Nursing Process:
Analysis MSC: NCLEX: Physiological Integrity
CHAPTER 19 SUBSTANCE RELATED AND
ADDICTIVE DISORDER QUESTIONS WITH
WELL EXPLAINED ANSWERS(WITH REF) A
GRADE| UPDATE 2024 REAL EXAM!!
Chapter 19: Substance-Related and Addictive Disorders Test Bank
MULTIPLE CHOICE
1. 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)
ANS: 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.
DIF: Cognitive Level: Application REF: Pages: 336-367
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. 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
ANS: 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.
DIF: Cognitive Level: Application REF: Page: 363
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
, 3. 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
, ANS: 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.
DIF: Cognitive Level: Comprehension REF: Page: 367
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. 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.
ANS: 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.
DIF: Cognitive Level: Application REF: Pages: 366-368
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. 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
ANS: 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.
DIF: Cognitive Level: Analysis REF: Pages: 372-
373 TOP: Nursing Process: Diagnosis| Nursing Process:
Analysis MSC: NCLEX: Physiological Integrity
