ATI LPN
Test Bank for Psychiatric Nursing: Contemporary Practice
Chapter 30 : Addiction and Substance-Related Disorders Questions
Question 1 of 5
The nurse is completing the admission of a client who is seeking treatment for alcoholism. He tells the nurse that the last time he had any alcohol to drink was at 10:00 AM before he left for the hospital. The nurse closely monitors the client. Which of the following would lead the nurse to suspect that the client is experiencing stage 1 of alcohol withdrawal syndrome? Select all that apply.
Correct Answer: A,B,E
Rationale: Stage 1 alcohol withdrawal (6?24 hours post-last drink) includes slight diaphoresis (
A), hand tremors (
B), and normal blood pressure (E). Intermittent confusion (
C) and heart rate of 135 (
D) are more typical of later stages like delirium tremens.
Question 2 of 5
A nurse is talking with a 57-year-old client who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit. It is 5:00 AM, and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that basically describes how her nursing supervisor came to visit and gave it to her to wear so she?d remember to get well. The nurse suspects that the client may be experiencing which of the following?
Correct Answer: C
Rationale: The client?s confabulation (fabricated story about the stethoscope) and insomnia suggest Korsakoff?s psychosis (
C), a chronic condition from alcohol-related thiamine deficiency causing memory deficits. Wernicke?s syndrome (
A) involves ataxia and confusion, delirium tremens (
B) includes severe autonomic symptoms, and malignant hyperthermia (
D) is unrelated to alcohol.
Question 3 of 5
A nurse is using motivational therapy with a female client with alcoholism. The client, who is unwilling to consider changing her drinking behavior, emphatically states, I am not an alcoholic; you can?t make me stop drinking. Which response by the nurse would be most appropriate?
Correct Answer: D
Rationale: Motivational interviewing emphasizes autonomy, making the response that only the client can choose to stop drinking (
D) most appropriate. Confronting about driving (
A) or relationships (
C) may increase resistance, and agreeing with denial (
B) is non-therapeutic.
Question 4 of 5
A 52-year-old male client who has a history of alcohol dependence is admitted to a detoxification unit. He has tremors, he is anxious, his pulse has risen from 98 to 110 beats/min, his blood pressure has risen from 140/88 to 152/100 mm Hg, and his temperature is six tenths of a degree above normal. He is slightly diaphoretic. Which nursing diagnosis would be the priority?
Correct Answer: B
Rationale: The client?s symptoms (tremors, anxiety, elevated vitals, diaphoresis) indicate early alcohol withdrawal, making Risk for Injury (
B) the priority due to potential progression to seizures or delirium. Thought processes (
A), coping (
C), and denial (
D) are secondary concerns.
Question 5 of 5
A nurse is working with a client who is addicted to heroin. The nurse engages in harm reduction by teaching the client about which of the following?
Correct Answer: A
Rationale: Harm reduction in heroin addiction includes teaching needle disinfection with bleach (
A) to reduce infection risk. Problem solving (
B) and coping skills (
C) are broader interventions, and naltrexone (
D) is more relevant for alcohol or opioid relapse prevention.