NSG 322 Final Exam: Questions With Accurate
Solutions
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." Right 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 incorrect.
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. Right 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.
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 Right 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.
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. Right 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
A 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 Right Ans - D
The client's clouded sensorium, sensory perceptual distortions, and
poor judgment predispose a risk for injury. Safety is the nurse's
priority. The other diagnoses may apply but are not the priorities of
care since none are related to the client's physical needs.
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.
Right 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.
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 Right 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.
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." Right 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.
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." Right 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
Solutions
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." Right 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 incorrect.
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. Right 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.
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 Right 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.
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. Right 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
A 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 Right Ans - D
The client's clouded sensorium, sensory perceptual distortions, and
poor judgment predispose a risk for injury. Safety is the nurse's
priority. The other diagnoses may apply but are not the priorities of
care since none are related to the client's physical needs.
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.
Right 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.
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 Right 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.
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." Right 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.
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." Right 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
