Ch.22- Substance Abuse

A patient diagnosed with alcoholism asks, “How will Alcoholics Anonymous (AA) help me?”

Select the nurse’s best response.

• “The goal of AA is for members to learn controlled drinking with the support of a

  higher power.”

• “An individual is supported by peers while striving for abstinence one day at a

  time.”

• “You must make a commitment to permanently abstain from alcohol and other

  drugs.”

• “You will be assigned a sponsor who will plan your treatment program.”

Answer explanation

Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and

receiving support from peers are basic aspects of AA. The other options are incorrect.

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The

medical record shows these blood pressure and pulse readings at the times listed:

0200: 118/78 mm Hg and 72 beats/min

0400: 126/80 mm Hg and 76 beats/min

0600: 128/82 mm Hg and 72 beats/min

0800: 132/88 mm Hg and 80 beats/min

1000: 148/94 mm Hg and 96 beats/min

What is the nurse’s priority action?

• Force fluids.

• Consult the health care provider.

• Obtain a clean-catch urine sample.

• Place the patient in a vest-type restraint.

Answer explanation

Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical

intervention. No indication is present that the patient may have a urinary tract infection or is presently in

need of restraint. Hydration will not resolve the problem.

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the

highest priority?

• Cardiovascular

• Respiratory

• Neurologic

• Hepatic

Answer explanation

Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death

among opioid abusers. The assessment of the other body systems is relevant but not the priority. See

relationship to audience response question.

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The

patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130

beats/min. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” Select

the most accurate assessment of this situation. The patient:

• is attempting to obtain attention by manipulating staff.

• may have sustained a head injury before admission.

• has symptoms of alcohol-withdrawal delirium.

• is having an acute psychosis.

Answer explanation

Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium.

The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on

the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?

• Disturbed sensory perception

• Ineffective coping

• Ineffective denial

• Risk for Injury

Answer explanation

The patient’s clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for

injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care.

A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are

snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can

anticipate the health care provider will prescribe a(n):

• narcotic analgesic, such as hydromorphone (Dilaudid).

• sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).

• antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril).

• monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).

Answer explanation

Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most

regions because of their high therapeutic safety index and anticonvulsant properties.

A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning

entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing

intervention is indicated?

• Check the patient every 15 minutes

• One-on-one supervision

• Keep the room dimly lit

• Force fluids

Answer explanation

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 room

promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention

normally occurs when blood alcohol levels fall.

A patient diagnosed with an alcohol abuse disorder says, “Drinking helps me cope with being a

single parent.” Which therapeutic response by the nurse would help the patient conceptualize the

drinking objectively?

• “Sooner or later, alcohol will kill you. Then what will happen to your children?”

• “I hear a lot of defensiveness in your voice. Do you really believe this?”

• “If you were coping so well, why were you hospitalized again?”

• “Tell me what happened the last time you drank.”

Answer explanation

The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin

to take responsibility. This approach can help the patient become receptive to the possibility of change.

The other 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. Select the nurse’s best response.

“Alcoholics Anonymous is a:

• form of group therapy led by a psychiatrist.”

• self-help group for which the goal is sobriety.”

• group that learns about drinking from a group leader.”

• network that advocates strong punishment for drunk drivers.”

Answer explanation

Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor

peer leaders are appointed.

Police bring a patient to the emergency department after an automobile accident. The patient

demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the

relationship between the behavior and blood alcohol level, which conclusion is most probable? The

patient:

• rarely drinks alcohol.

• has a high tolerance to alcohol.

• has been treated with disulfiram (Antabuse).

• has ingested both alcohol and sedative drugs recently.

Answer explanation

A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. The fact that the patient

is moving and talking shows a discrepancy between blood alcohol level and expected behavior and

strongly indicates that the patient’s body is tolerant. If disulfiram and alcohol are ingested together, an

entirely different clinical picture would result. The blood alcohol level gives no information about

ingestion of other drugs.