NUR 316 Exam 2 Question & Answers, All Rated-What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
- Risk for injury R/T central nervous system stimulation
A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within...
NUR 316 Exam 2 Question & Answers, All Rated
What should be the priority nursing diagnosis for a client experiencing alcohol
withdrawal?
- Risk for injury R/T central nervous system stimulation
A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100
attempts within a 30-minute period. Which is the best rationale for assessing this client
for substance use disorder?
- Clients who are regularly using alcohol or benzodiazepines may have developed cross-
tolerance to analgesics and require increased doses to achieve effective pain control.
On the first day of a client's alcohol detoxification, which nursing intervention should
take priority?
- Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
Which client statement indicates a knowledge deficit related to substance use?
- "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."
A lonely, depressed divorcée has been self-medicating with cocaine for the past year.
Which term should a nurse use to best describe this individual's situation?
- The individual is experiencing psychological addiction.
Which term should a nurse use to describe the administration of a central nervous system
(CNS) depressant during alcohol withdrawal?
- Substitution therapy
A client diagnosed with chronic alcohol use disorder is being discharged from an
inpatient treatment facility after detoxification. Which client outcome related to
Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the
client during discharge teaching?
- After discharge, the client will immediately attend 90 AA meetings in 90 days.
A client with a history of heavy alcohol use is brought to an emergency department (ED)
by family members who state that the client has had nothing to drink in the last 24 hours.
Which client symptom should the nurse immediately report to the ED physician?
, - Blood pressure of 180/100 mm Hg
Which client statement demonstrates positive progress toward recovery from a substance
use disorder?
- Taking those pills got out of control. It cost me my job, marriage, and children."
A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's
rationale for this intervention?
- To assess for fine tremors
Upon admission for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3
days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry
skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing
diagnosis?
- Imbalanced nutrition: less than body requirements
A mother who has a history of chronic heroin use has lost custody of her children due to
abuse and neglect. She has been admitted to an inpatient drug rehabilitation program.
Which client statement should a nurse associate with a positive prognosis for this client?
- "I cannot control my use of heroin. It's stronger than I am."
A client's wife has been making excuses for her alcoholic husband's work absences. In
family therapy, she states, "I just need to work harder to get him there on time." Which is
the appropriate nursing response?
- "Your husband needs to deal with the consequences of his drinking."
Which medication orders should a nurse anticipate for a client who has a history of
complicated withdrawal from benzodiazepines?
- hlordiazepoxide (Librium) and phenytoin (Dilantin)
During group therapy, a client diagnosed with alcohol use disorder states, "I would not
have boozed it up if my wife hadn't been nagging me all the time to get a job. She never
did think that I was good enough for her." How should a nurse interpret this statement?
- The client is using rationalization to excuse his alcohol dependence.
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