Test bank For Varcarolis Foundations of Psychiatric-Mental
Health Nursing 9th Edition 9780323697071 | All Chapters with
Answers and Rationals
A Client diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA)
help me?" What is the nurse's best response?
a. "The goal of AA is for members to learn controlled drinking with the support of a
higher power."
b. "An individual is supported by peers while striving for abstinence one day at a
time."
c. "You must make a commitment to permanently abstain from alcohol and other
drugs."
d. "You will be assigned a sponsor who will plan your treatment program." - ANSWER: ANS: B
Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and
receiving support from peers are basic aspects of AA. The other options are incorrec
A nurse reviews vital signs for a client admitted with an injury sustained while intoxicated. The
medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm
Hg and 72 beats/minute
0400: 126/80 mm Hg and 76 beats/minute
0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94
mm Hg and 96 beats/minute What is the nurse's priority action?
a. Force fluids.
b. Begin the detox protocol.
c. Obtain a clean-catch urine sample.
d. Place the Client in a vest-type restraint. - ANSWER: ANS: B
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox
with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present
that the Client may have a urinary tract infection or is presently in need of restraint. Hydration will not
resolve the problem.
PTS: 1 DIF: Cognitive Level: Analyze (A
A nurse cares for a client experiencing an opioid overdose. Which focused assessment has the
highest priority?
a. Cardiovascular
b. Respiratory
c. Neurological
d. Hepatic - ANSWER: ANS: B
Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death
among opioid abusers. The assessment of the other body systems is relevant but not the priority.
PTS:
4. A client admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The
client is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130
beats/minute. The client shouts, "Bugs are crawling on my bed. I've got to get out of here." What is
the most accurate assessment of this situation?
a. The client is attempting to obtain attention by manipulating staff.
b. The client may have sustained a head injury before admission.
c. The client has symptoms of alcohol withdrawal delirium.
d. The client is having an acute psychosis. - ANSWER: ANS: C
Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal
delirium. The findings are inconsistent with manipulative attempts, head injury, or functional
psychosis.
,client admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the
bed. The client is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
a. Disturbed sensory perception
b. Ineffective coping
c. Ineffective denial
d. Risk for injury - ANSWER: D
A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying
to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the
health care provider will prescribe what medication intervention?
a. narcotic analgesic, such as hydromorphone.
b. sedative, such as lorazepam or chlordiazepoxide.
c. antipsychotic, such as olanzapine or thioridazine.
d. monoamine oxidase inhibitor antidepressant, such as phenelzine. - ANSWER: ANS: B
Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most
regions because of their high therapeutic safety index and anticonvulsant properties. The client's
highest needs related to a need for calming.
PTS: 1 DIF: Cognitive Level: Apply (Appli
7. A hospitalized Client diagnosed with alcohol use disorder believes spiders are spinning entrapping
webs in the room. The client is fearful, agitated, and diaphoretic. Which nursing intervention is
indicated?
a. Check the client every 15 minutes
b. One-on-one supervision
c. Keep the room dimly lit
d. Force fluids - ANSWER: ANS: B
One-on-one supervision is necessary to promote physical safety until sedation reduces the Client's
feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit
room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid
retention normally occurs when blood alcohol levels fall.
8. A client diagnosed with alcohol use disorder says, "Drinking helps me cope with being a single
parent." Which therapeutic response by the nurse would help the client conceptualize the drinking
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." - ANSWER: ANS: D
The correct response will help the client see alcohol as a cause of the problems, not a solution, and
begin to take responsibility. This approach can help the client become receptive to the possibility of
change. The other responses directly confront and attack defenses against anxiety that the client still
needs. They reflect the nurse's frustration with the client.
9. A Client asks for information about alcoholics anonymous (AA). What is the nurse's best response?
"
a. AA is a form of group therapy led by a psychiatrist."
b. AA is a self-help group for which the goal is sobriety."
c. AA is a group that learns about drinking from a group leader."
d. AA is a network that advocates strong punishment for drunk drivers." - ANSWER: ANS: B
AA is a peer support group for recovering alcoholics. Neither professional nor peer leaders are
appointed. AA does not advocate punishment but supports accountability for one's actions.
Police bring a client to the emergency department after an automobile accident. The client
demonstrates poor coordination and slurred speech, but the vital signs are normal. The blood alcohol
level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and
blood alcohol level, which conclusion is most probable?
a. The client rarely drinks alcohol.
, b. The client has a high tolerance to alcohol.
c. The client has been treated with disulfiram.
d. The client has ingested both alcohol and sedative drugs recently. - ANSWER: ANS: B
A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol
level of 300 mg/dL (0.30 g/dL). The fact that the client is moving and talking shows a discrepancy
between blood alcohol level and expected behavior and strongly indicates that the client's body is
tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would
result. The blood alcohol level gives no information about ingestion of other drugs.
client admitted to an alcohol rehabilitation program tells the nurse, "I'm actually just a social drinker. I
usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the
evening." The client is using which defense mechanism?
a. Denial
b. Projection
c. Introjection
d. Rationalization - ANSWER: ANS: A
Minimizing one's drinking is a form of denial of alcoholism. The Client is more than a social drinker.
Projection involves blaming another for one's faults or problems. Rationalization involves making
excuses. Introjection involves incorporating a quality of another person or group into one's own
personality.
12. Which medication to maintain abstinence would most likely be prescribed for clients diagnosed
with an addiction to either alcohol or opioids?
a. Bromocriptine
b. Methadone
c. Disulfiram
d. Naltrexone - ANSWER: ANS: D
Naltrexone is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the
action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.
None of the other options are associated with such a response.
13. During the third week of treatment, the spouse of a client in a rehabilitation program for
substance abuse says, "After this treatment program, I think everything will be all right." Which
remark by the nurse will be most helpful to the spouse?
a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs
and alcohol."
b. "It will be important for you to structure life to avoid as much stress as you can and provide social
protection."
c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior
carefully."
d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it." -
ANSWER: ANS: A
During recovery, clients identify and use alternative coping mechanisms to reduce reliance on
substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol
but are now fully experienced and may cause considerable anxiety. These changes inevitably have an
effect on the spouse and children, who need anticipatory guidance and accurate information
The treatment team discusses the plan of care for a client diagnosed with schizophrenia and daily
cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the
team should consider what intervention?
a. provide long-term care for the client in a residential facility.
b. withdraw the client from cannabis, then treat the schizophrenia.
c. consider each diagnosis primary and provide simultaneous treatment.
d. first treat the schizophrenia, then establish goals for substance abuse treatment.
ANS: C
Both diagnoses should be considered primary and receive simultaneous treatment. Co - ANSWER: C
Health Nursing 9th Edition 9780323697071 | All Chapters with
Answers and Rationals
A Client diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA)
help me?" What is the nurse's best response?
a. "The goal of AA is for members to learn controlled drinking with the support of a
higher power."
b. "An individual is supported by peers while striving for abstinence one day at a
time."
c. "You must make a commitment to permanently abstain from alcohol and other
drugs."
d. "You will be assigned a sponsor who will plan your treatment program." - ANSWER: ANS: B
Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and
receiving support from peers are basic aspects of AA. The other options are incorrec
A nurse reviews vital signs for a client admitted with an injury sustained while intoxicated. The
medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm
Hg and 72 beats/minute
0400: 126/80 mm Hg and 76 beats/minute
0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94
mm Hg and 96 beats/minute What is the nurse's priority action?
a. Force fluids.
b. Begin the detox protocol.
c. Obtain a clean-catch urine sample.
d. Place the Client in a vest-type restraint. - ANSWER: ANS: B
Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox
with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present
that the Client may have a urinary tract infection or is presently in need of restraint. Hydration will not
resolve the problem.
PTS: 1 DIF: Cognitive Level: Analyze (A
A nurse cares for a client experiencing an opioid overdose. Which focused assessment has the
highest priority?
a. Cardiovascular
b. Respiratory
c. Neurological
d. Hepatic - ANSWER: ANS: B
Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death
among opioid abusers. The assessment of the other body systems is relevant but not the priority.
PTS:
4. A client admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The
client is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130
beats/minute. The client shouts, "Bugs are crawling on my bed. I've got to get out of here." What is
the most accurate assessment of this situation?
a. The client is attempting to obtain attention by manipulating staff.
b. The client may have sustained a head injury before admission.
c. The client has symptoms of alcohol withdrawal delirium.
d. The client is having an acute psychosis. - ANSWER: ANS: C
Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal
delirium. The findings are inconsistent with manipulative attempts, head injury, or functional
psychosis.
,client admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the
bed. The client is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
a. Disturbed sensory perception
b. Ineffective coping
c. Ineffective denial
d. Risk for injury - ANSWER: D
A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying
to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the
health care provider will prescribe what medication intervention?
a. narcotic analgesic, such as hydromorphone.
b. sedative, such as lorazepam or chlordiazepoxide.
c. antipsychotic, such as olanzapine or thioridazine.
d. monoamine oxidase inhibitor antidepressant, such as phenelzine. - ANSWER: ANS: B
Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most
regions because of their high therapeutic safety index and anticonvulsant properties. The client's
highest needs related to a need for calming.
PTS: 1 DIF: Cognitive Level: Apply (Appli
7. A hospitalized Client diagnosed with alcohol use disorder believes spiders are spinning entrapping
webs in the room. The client is fearful, agitated, and diaphoretic. Which nursing intervention is
indicated?
a. Check the client every 15 minutes
b. One-on-one supervision
c. Keep the room dimly lit
d. Force fluids - ANSWER: ANS: B
One-on-one supervision is necessary to promote physical safety until sedation reduces the Client's
feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit
room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid
retention normally occurs when blood alcohol levels fall.
8. A client diagnosed with alcohol use disorder says, "Drinking helps me cope with being a single
parent." Which therapeutic response by the nurse would help the client conceptualize the drinking
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." - ANSWER: ANS: D
The correct response will help the client see alcohol as a cause of the problems, not a solution, and
begin to take responsibility. This approach can help the client become receptive to the possibility of
change. The other responses directly confront and attack defenses against anxiety that the client still
needs. They reflect the nurse's frustration with the client.
9. A Client asks for information about alcoholics anonymous (AA). What is the nurse's best response?
"
a. AA is a form of group therapy led by a psychiatrist."
b. AA is a self-help group for which the goal is sobriety."
c. AA is a group that learns about drinking from a group leader."
d. AA is a network that advocates strong punishment for drunk drivers." - ANSWER: ANS: B
AA is a peer support group for recovering alcoholics. Neither professional nor peer leaders are
appointed. AA does not advocate punishment but supports accountability for one's actions.
Police bring a client to the emergency department after an automobile accident. The client
demonstrates poor coordination and slurred speech, but the vital signs are normal. The blood alcohol
level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and
blood alcohol level, which conclusion is most probable?
a. The client rarely drinks alcohol.
, b. The client has a high tolerance to alcohol.
c. The client has been treated with disulfiram.
d. The client has ingested both alcohol and sedative drugs recently. - ANSWER: ANS: B
A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol
level of 300 mg/dL (0.30 g/dL). The fact that the client is moving and talking shows a discrepancy
between blood alcohol level and expected behavior and strongly indicates that the client's body is
tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would
result. The blood alcohol level gives no information about ingestion of other drugs.
client admitted to an alcohol rehabilitation program tells the nurse, "I'm actually just a social drinker. I
usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the
evening." The client is using which defense mechanism?
a. Denial
b. Projection
c. Introjection
d. Rationalization - ANSWER: ANS: A
Minimizing one's drinking is a form of denial of alcoholism. The Client is more than a social drinker.
Projection involves blaming another for one's faults or problems. Rationalization involves making
excuses. Introjection involves incorporating a quality of another person or group into one's own
personality.
12. Which medication to maintain abstinence would most likely be prescribed for clients diagnosed
with an addiction to either alcohol or opioids?
a. Bromocriptine
b. Methadone
c. Disulfiram
d. Naltrexone - ANSWER: ANS: D
Naltrexone is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the
action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.
None of the other options are associated with such a response.
13. During the third week of treatment, the spouse of a client in a rehabilitation program for
substance abuse says, "After this treatment program, I think everything will be all right." Which
remark by the nurse will be most helpful to the spouse?
a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs
and alcohol."
b. "It will be important for you to structure life to avoid as much stress as you can and provide social
protection."
c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior
carefully."
d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it." -
ANSWER: ANS: A
During recovery, clients identify and use alternative coping mechanisms to reduce reliance on
substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol
but are now fully experienced and may cause considerable anxiety. These changes inevitably have an
effect on the spouse and children, who need anticipatory guidance and accurate information
The treatment team discusses the plan of care for a client diagnosed with schizophrenia and daily
cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the
team should consider what intervention?
a. provide long-term care for the client in a residential facility.
b. withdraw the client from cannabis, then treat the schizophrenia.
c. consider each diagnosis primary and provide simultaneous treatment.
d. first treat the schizophrenia, then establish goals for substance abuse treatment.
ANS: C
Both diagnoses should be considered primary and receive simultaneous treatment. Co - ANSWER: C
