Exam 5 Mental Health Nursing
- A nurse evaluates a client’s PCA pump and notices 100 attempts within a 30 min period. Which is the best rationale for assessing this client for substance abuse?
- Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control.
- Which client statement indicates a knowledge deficit related to a substance use disorder?
- “Marijuana is like smoking cigarettes. Everyone does it, it’s essentially harmless.”
- A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to 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 the emergency room. By family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse's first priority?
Blood pressure 180/100
- Which statement demonstrates positive progress toward recovery from a substance abuse disorder?
- “taking those pills got out of control. It cost me my job, marriage, and children.”
- A nurse holds the hands of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention?
To assess for fine tremors.
- A client’s wife begins making excuses for her alcoholic husbands work absences. In family therapy, she states, “his problems at work are my fault.” Which is the appropriate nursing response?
“Your husband needs to deal with the consequences of his drinking.”
- A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
The client will correlate life problems with alcohol use.
A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
- 100 mg/dL
A client is admitted to the ED & is tested for blood alcohol level (BAL). The client has a BAL of 0.10 g/ dL. What is an accurate interpretation of this lab value?
The client is legally intoxicated (it’s above 0.08%).
- A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands a psychiatrist to prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try non pharmacological interventions?
- sedative hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance.
- A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed?
- “all state boards of nursing have passed laws that, under by any circumstances, do not allow impaired nurses to practice.”
- Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for a client diagnosed with substance related disorder. (SATA)
- “I am easily manipulated and need to work on this prior to caring for these clients.”
- “Because of my fathers alcoholism, I need to examine my attitude toward these clients.”
- “I’ll need to set boundaries to maintain a therapeutic relationship.”
- A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.)
- A.) "A diet rich in protein will promote hepatic healing."
- C.) "In this condition, blood accumulates in the abdominal cavity."
- A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?
- Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
- A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect the nurse is impaired? (select all that apply)
- The staff nurse experiences mood swings
- The staff nurse makes elaborate excuses for behavior
- The staff nurse frequently uses the restroom
- The staff nurse has a flushed face
What is true about the outcomes of nursing interventions?
Outcomes should be tailored to an individual’s needs and abilities.
- A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (select all that apply)
- The client has a long history of focusing thoughts and behaviors on other people
- The client is a people pleaser and will do almost anything to gain approval
- The client can achieve a sense of control only through fulfilling the needs of others.
Know about naltrexone (Revia)
- not habit forming and works on receptors in brain that produce pleasure but doesn’t produce “narcotic high”
- Info: Intended effects- pure opioid antagonist that suppresses craving & pleasurable effects of alcohol (also used for opioid withdrawal).
- Nursing Considerations:
- Assess pt hx to determine if pt is also dependent on opioids b/c concurrent use increases risk of OD of opiates.
- Advise pt to take naltrexone w/ meals to decrease GI upset.
- Suggest monthly Im injections of depot naltrexone for pts who have difficulty adhering to the medication regimen.
- Highest priority-nurse asks newly admitted client with history of alcohol abuse is ___what
- When was the last time you had a drink/how much
- Three days after surgery to correct a perforated bowel, a client begins to display signs and symptoms of tremors, increased blood pressure, and diaphoresis. What should the nurse suspect?
Alcohol or other CNS depressants induced withdrawal.
- When questioned about bruises, a woman states, “it was an accident. My husband just has a bad day at work. He is so gentle now and even brought me flowers. He is going to get a new job, so it won’t happen again. This client is in which phase of the cycle of battering?
- Phase 3: the honeymoon phase
- Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse?
- have ready access to the number of a safe house for battered women.
- Different types of rapist (characteristics)
- Power assertive- wants to dominate and control victim, finds vic in bars/ internet
- Anger retaliation- Wants to punish a victim, dislikes women, often causes injury
- Power reassurance/ opportunity- When opportunity presents itself, lonely call my keep souvenirs, thanks a victim likes it
- Anger excitability/ sadistic- Wants to hurt victam, sometimes a victim is killed, acts out fantasies, bites or Burns victim