ATI LPN
Psychiatric Nursing: Contemporary Practice 6th Edition
Chapter 30 : Addiction and Substance-Related Disorders Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A 20-year-old man arrives at the emergency department by ambulance. He is unconscious, with slow respirations and pinpoint pupils. There are tracks visible on his arms. The friend who came with him reports that the client had just shot up heroin when he became unconscious. Which medication would the nurse most likely expect to administer?
Correct Answer: A
Rationale: Naloxone (
A) is an opioid antagonist used to reverse heroin overdose, counteracting respiratory depression and unconsciousness. Naltrexone (
B) is for maintenance, bupropion (
C) is for depression/smoking cessation, and varenicline (
D) is for smoking cessation.