ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 71 : Caring for Clients With Substance Use Disorders Questions
Question 1 of 5
A client is brought to the emergency department with hallucinations, acne, and blackened teeth. During the nursing assessment, a generalized seizure begins. The nurse interprets this as possible toxicity by which substance?
Correct Answer: D
Rationale: Methamphetamine users may develop acne, 'meth mouth,' tactile hallucinations, and can develop convulsions, respiratory, and cardiac arrest. Cocaine and opiate dependence do not result in the inclusion of the symptoms presented, but the nurse should understand that poly drug use disorder is common.
Question 2 of 5
Which assessment finding is most important in determining nursing care of a client withdrawing from cocaine?
Correct Answer: A
Rationale: Depression and dysphoria are of concern during recovery from cocaine addiction. Monitoring the client for suicidal ideation and administering medications that provide support during withdrawal are essential nursing interventions. Weight loss and nutritional deficits are common among cocaine addiction but not the primary concern. Facial burns (fire, debasing) and perforated septum (from snorting) are common problems associated with cocaine addiction.
Question 3 of 5
A client has overdosed on opiates. Which drug would the nurse anticipate being ordered for this client?
Correct Answer: C
Rationale: Opiate overdose leads to respiratory depression, unconsciousness, and death. Naloxone is administered to reverse the effects of opiates and assists in restoring respiration. Naltrexone is an opiate antagonist that is used for rapid opiate detoxification while the client is under anesthesia. Dolphine and hydromorphone are opiate drugs and would increase the effects of respiratory depression.
Question 4 of 5
The client who is experiencing alcohol withdrawal has a temperature of 100.6?°F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?
Correct Answer: B
Rationale: The standardized symptom withdrawal flow sheet, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) as well as the Rule of One Hundreds are indicators of escalating withdrawal. The rise in these vital signs suggests the need for sedative medication. Monitoring hourly vital signs and further changes would be appropriate. Rest and emotional support can be helpful.
Question 5 of 5
Which is the best nursing intervention to prevent a potential depressant action of methadone caused by mixing with another drug?
Correct Answer: A
Rationale: The practice of testing the urine before providing methadone is one way of screening and eliminating those who are abusing the system and trying to potentiate the effects of the methadone by combining with another depressant. The methadone should be administered by a professional and supplied in a liquid form to avoid cheeking of the drug. Addictive clients are drug-seeking in nature and cannot be trusted to always be honest with drug use questioning and answers. Vital sign monitoring is not significant in the detection of alternate drug use.