Mental Health Final Last CH 22,23,30
QUESTIONS AND CORRECT
ANSWERS
GRADE A+
1.
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." 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. 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 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. 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 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.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 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." 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." 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. 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 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?
QUESTIONS AND CORRECT
ANSWERS
GRADE A+
1.
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." 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. 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 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. 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 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.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 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." 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." 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. 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 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?
