Module 15 - Mental Health Nursing -
Review Questions
What is drug tolerance? - answer-A physiological experience that occurs when a
person’s reaction to a substance decreases with repeated administrations of the same
dose
What is the difference between physical vs psychological dependence? - answer-
Physical dependence is considered tolerance and withdrawal
-Psychological dependence is the dependence on the drugs or the substance of choice
What is CAGE assessment for alcohol intoxication? - Answer-Cut down (have you tried
to cut down)
-Annoyed (do friends and family get annoyed)
-Guilty (do they feel guilty about drinking)
-Eye opener (is it the first thing they do when they wake up)
What are the nursing interventions for alcohol intoxication? - answer-State of toxicity
that results from consumption of large quantities of alcohol
-Risk for aspiration of emesis or severe CNS depression
——Inability to rouse patient, sever dehydration, cool, clammy skin, respirations less
than 10 per minute, cyanosis of the gums, and emesis wile semi or unconscious
*Interventions:*
-Maintaining a calm and quite environment
-Protect airway and prevent aspiration
What's the priority nursing diagnosis for alcohol withdrawal? - answer*-Risk for self
harm*
-Risk for dehydration and electrolyte imbalance
What's the medical treatment for alcohol withdrawal? - answer-Benzodiazepine (anti-
anxiety agent), given to calm the body and slow the effects of alcohol withdrawal
-Medical stabilization
-Alcohol withdrawal peaks at 24-48 hours and then rapidly goes away unless delirium is
present (if alcohol has been used heavily for 5-15 years or more delirium may be
present)
What is CIWA scoring and when it's done? - answer-Used for alcohol withdrawal
-Assesses for N&V, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances,
auditory disturbances, visual disturbances, headache and altered orientation
Review Questions
What is drug tolerance? - answer-A physiological experience that occurs when a
person’s reaction to a substance decreases with repeated administrations of the same
dose
What is the difference between physical vs psychological dependence? - answer-
Physical dependence is considered tolerance and withdrawal
-Psychological dependence is the dependence on the drugs or the substance of choice
What is CAGE assessment for alcohol intoxication? - Answer-Cut down (have you tried
to cut down)
-Annoyed (do friends and family get annoyed)
-Guilty (do they feel guilty about drinking)
-Eye opener (is it the first thing they do when they wake up)
What are the nursing interventions for alcohol intoxication? - answer-State of toxicity
that results from consumption of large quantities of alcohol
-Risk for aspiration of emesis or severe CNS depression
——Inability to rouse patient, sever dehydration, cool, clammy skin, respirations less
than 10 per minute, cyanosis of the gums, and emesis wile semi or unconscious
*Interventions:*
-Maintaining a calm and quite environment
-Protect airway and prevent aspiration
What's the priority nursing diagnosis for alcohol withdrawal? - answer*-Risk for self
harm*
-Risk for dehydration and electrolyte imbalance
What's the medical treatment for alcohol withdrawal? - answer-Benzodiazepine (anti-
anxiety agent), given to calm the body and slow the effects of alcohol withdrawal
-Medical stabilization
-Alcohol withdrawal peaks at 24-48 hours and then rapidly goes away unless delirium is
present (if alcohol has been used heavily for 5-15 years or more delirium may be
present)
What is CIWA scoring and when it's done? - answer-Used for alcohol withdrawal
-Assesses for N&V, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances,
auditory disturbances, visual disturbances, headache and altered orientation
