@PROFDOCDIGITALLIBRARIES
RNSG 2213 - Level 3- Review for Exam 3-with 100%
verified solutions-2024/2025 Version ||
Complete Guide A+
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)
PR
d. About 0200 on hospital day 4 (96 hours after drinking stopped)
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.
O
FD
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
O
c. healthy but underweight
d. microcephalic and cognitively impaired
C
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.
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
,@PROFDOCDIGITALLIBRARIES
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.
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.
PR
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.
O
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
FD
injury, or functional psychosis.
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
O
diagnosis?
a. Ineffective airway clearance
C
b. Ineffective coping
c. Ineffective denial
d. Risk for injury
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
,@PROFDOCDIGITALLIBRARIES
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are
snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which
medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine
C
Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in
most regions because of their high therapeutic safety index and anticonvulsant properties.
PR
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping
webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has
priority?
a. Check the patient every 15 minutes.
O
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
FD
d. Keep the room dimly lit.
C
One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's
feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit
O
room promotes illusions. Oral fluids are important, but safety is a higher priority.
C
An alcohol-dependent individual says, "Drinking helps me cope with being a single parent." Which
response by the nurse would help the individual conceptualize the drinking more 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."
D
, @PROFDOCDIGITALLIBRARIES
The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the
problems, not the solution. This approach can also help the patient become receptive to the
possibility of change. The incorrect responses directly confront and attack defenses against anxiety
that the patient still needs. They reflect the nurse's frustration with the patient.
A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best
response?
a. "It is a self-help group with the goal of sobriety."
b. "It is a form of group therapy led by a psychiatrist."
c. "It is a group that learns about drinking from a group leader."
d. "It is a network that advocates strong punishment for drunk drivers."
PR
A
AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither
professional nor peer leaders are appointed.
O
Police bring a patient to the emergency department after an automobile accident. The patient is
FD
ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %).
Considering the relationship between behavior and blood alcohol level, which conclusion can the
nurse draw? The patient:
a. rarely drinks alcohol.
O
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
C
d. has recently ingested both alcohol and sedative drugs.
B
A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The
fact that the patient is walking and talking shows a discrepancy between blood alcohol level and
expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If
disulfiram and alcohol are ingested together, then an entirely different clinical picture would result.
The blood alcohol level gives no information about the ingestion of other drugs.
A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually
have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks
during the evening." Which defense mechanism is evident?
RNSG 2213 - Level 3- Review for Exam 3-with 100%
verified solutions-2024/2025 Version ||
Complete Guide A+
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)
PR
d. About 0200 on hospital day 4 (96 hours after drinking stopped)
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.
O
FD
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
O
c. healthy but underweight
d. microcephalic and cognitively impaired
C
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.
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
,@PROFDOCDIGITALLIBRARIES
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.
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.
PR
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.
O
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
FD
injury, or functional psychosis.
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
O
diagnosis?
a. Ineffective airway clearance
C
b. Ineffective coping
c. Ineffective denial
d. Risk for injury
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
,@PROFDOCDIGITALLIBRARIES
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are
snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which
medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine
C
Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in
most regions because of their high therapeutic safety index and anticonvulsant properties.
PR
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping
webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has
priority?
a. Check the patient every 15 minutes.
O
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
FD
d. Keep the room dimly lit.
C
One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's
feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit
O
room promotes illusions. Oral fluids are important, but safety is a higher priority.
C
An alcohol-dependent individual says, "Drinking helps me cope with being a single parent." Which
response by the nurse would help the individual conceptualize the drinking more 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."
D
, @PROFDOCDIGITALLIBRARIES
The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the
problems, not the solution. This approach can also help the patient become receptive to the
possibility of change. The incorrect responses directly confront and attack defenses against anxiety
that the patient still needs. They reflect the nurse's frustration with the patient.
A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best
response?
a. "It is a self-help group with the goal of sobriety."
b. "It is a form of group therapy led by a psychiatrist."
c. "It is a group that learns about drinking from a group leader."
d. "It is a network that advocates strong punishment for drunk drivers."
PR
A
AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither
professional nor peer leaders are appointed.
O
Police bring a patient to the emergency department after an automobile accident. The patient is
FD
ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %).
Considering the relationship between behavior and blood alcohol level, which conclusion can the
nurse draw? The patient:
a. rarely drinks alcohol.
O
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
C
d. has recently ingested both alcohol and sedative drugs.
B
A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The
fact that the patient is walking and talking shows a discrepancy between blood alcohol level and
expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If
disulfiram and alcohol are ingested together, then an entirely different clinical picture would result.
The blood alcohol level gives no information about the ingestion of other drugs.
A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually
have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks
during the evening." Which defense mechanism is evident?
