CHAPTER 11 11.1 The nurse is managing care for a group of substance abusers.

The clients have completed group education about the disease of addiction. The nurse determines that learning has occurred when the clients make which statements? Select all that apply. 1. Addiction includes a compulsion to use a mood-altering substance. 2. Substance abuse depends on complex variables. 3. Most addicts became addicted from pain medication in a hospital. 4. There is most likely a genetic component to addiction. 5. A heroin addict can die from heroin withdrawal. Answer: 1, 2, 4 Rationale: Addiction is an overwhelming compulsion that drives someone to repetitive drug-taking behavior, despite serious health and social consequences. Substance abuse depends on multiple, complex, interacting variables. Children of alcoholic parents are four times more likely to become alcoholics than children of nonalcoholic parents. Prescription drugs rarely cause addiction when used according to accepted medical protocols. While extremely unpleasant, withdrawal from opioids is not life threatening. Evaluation Psychosocial Integrity Application Objective: 11-1 11.2 The adolescent client is in a drug rehabilitation program. The mother of this client says to the nurse The doctor said my son has a physical addiction to alcohol. What does this mean? What is the best response by the nurse? 1. He will have an intense craving for alcohol; this is best managed in group therapy. 2. His body is used to alcohol; he will have specific withdrawal symptoms when it is stopped. 3. His brain remembers the euphoria he had with alcohol, and he has a craving to return to it. 4. He will have feelings of depression when stopping alcohol; we need to monitor him for suicide. Answer: 2 Rationale: Over time, the bodys cells become accustomed to the presence of the unnatural substance. Specific, physical withdrawal symptoms will occur; the client needs to be medically withdrawn from the substance. Psychological dependence, or craving, does not involve physical withdrawal symptoms. Alcohol does produce euphoria, but a craving for the substance is not a medical issue. Depression may accompany physical withdrawal, but physical signs are what require medical management. Implementation Psychosocial Integrity Application Objective: 11-2 11.3 The client has an extensive history of alcoholism. He is having coronary bypass surgery. While administering anesthesia, the certified nurse anesthetist notes that the client requires higher-than-usual amounts of the drug. The nurse correctly evaluates this response as what phenomenon? 1. The nurse anesthetist most likely did not calculate the correct amount of anesthesia for this client. 2. The client has developed a resistance to the anesthesia, so it will not work very well. 3. The client has developed a paradoxical reaction to the anesthesia, and will require a different drug. 4. The client had developed cross-tolerance to the anesthesia, and will require higher amounts. Answer: 4

Rationale: With chronic alcohol use, the liver adapts and metabolizes alcohol at a faster rate. More of the substance is required to achieve the same effect. This is a phenomenon known as cross-tolerance. This client has a tolerance to alcohol, so he will require additional anesthesia for surgery since both drugs are CNS depressants. There is no evidence to support that the nurse anesthetist incorrectly calculated the anesthesia dose. Resistance refers to the immune system and infections, and should not be used interchangeably with tolerance. Paradoxical refers to the opposite response; in this case, the client would have become very excitable; there is no evidence of this. Evaluation Physiological Integrity Analysis Objective: 11-4 11.4 The client is post-op, day 1 after an abdominal hysterectomy and is requesting morphine sulfate intravenous (IV), which is prescribed. The client rates her pain as 8 out of 10, with 10 being the most intense. The nurse caring for this client says to another nurse She really doesnt look like she is in pain, maybe she is an addict. What is the best response by the other nurse? 1. I would give the morphine; pain is subjective, and we dont know her history. 2. I would hold the medication until she looks like she is in pain. 3. You could call the doctor and get an order for an oral medication. 4. Maybe you could tell her to do some distraction techniques first. Answer: 1 Rationale: The response to pain varies among individuals; a client is not an addict just because they do not look like they are in pain. Pain is subjective; the client should be believed. Holding a pain medication the first post-op day is inappropriate, since not all clients express pain in the same manner. Calling the physician for an order for an oral medication is inappropriate on the first post-op day. Distraction techniques would be a good adjunct to pain medication, but should not replace it. Implementation Physiological Integrity Application Objective: 11-1 11.5 The client comes to the emergency department and tells the nurse I have been off my drugs for 3 days. The nurse assesses the client for withdrawal symptoms associated with the category of drug used. Withdrawal from which drug, if taken by the client, should cause the nurse the most concern? 1. Cocaine 2. Heroin 3. Alprazolam (Xanax) 4. Marijuana Answer: 3 Rationale: Alprazolam (Xanax) is a benzodiazepine. This drug, which is a central nervous system (CNS) depressant, will likely lead to the most life-threatening withdrawal symptoms in a client who has stopped taking it. Withdrawal from heroin is very unpleasant, but it is not life-threatening. Withdrawal from cocaine is uncomfortable, but it is not life-threatening. There is virtually no withdrawal from marijuana. Assessment Psychosocial Integrity Application Objective: 11-3 11.6 The mother of an adolescent client says to the nurse I think my son is staying up too late studying, and I see him using Visine eye drops all the time for his red eyes. Should I have his vision checked? What is the best response by the nurse? 1. Yes, that is a great idea, he may need some glasses. 2. He might be depressed; insomnia is common with depression.

3. Sounds like he is using cocaine; I have seen this before. 4. Sounds like he is smoking marijuana, and I would talk to him. Answer: 4 Rationale: One hallmark symptom of marijuana use is red or bloodshot eyes, caused by dilation of blood vessels. Visine constricts the blood vessels of the eyes, reducing the redness. It is important for the parent to discuss this with the adolescent. Having the adolescents eyes checked may indicate that the mother is in denial, and that the nurse needs to be more alert to the signs and symptoms of drug abuse. Depression in this client is possible, but depressed clients do not always have red eyes, and do not commonly use Visine eye drops. Red or bloodshot eyes are not commonly seen with cocaine abuse, but are always seen with marijuana use. Implementation Psychosocial Integrity Application Objective: 11-5 11.7 The client has been abusing alcohol for several years and tells the nurse I used to drink a pint of whiskey every day. Now I get sick and pass out after just two drinks. What does the nurse correctly recognize about this client? 1. The client may have liver damage, resulting in an inability to metabolize large amounts of alcohol. 2. The client is in denial and is most likely minimizing the amount of alcohol he consumes. 3. The clients symptoms are related to hyperglycemia; he may have pancreatic damage. 4. The client has brain damage from the alcohol and cannot remember how much he consumes. Answer: 1 Rationale: Alcoholism is a common cause of cirrhosis, a debilitating, and often fatal, failure of the liver to perform its vital functions, such as metabolism of alcohol. While clients with alcoholism are frequently in denial, and tend to minimize the amount of alcohol they consume, this client is describing the results of liver damage. While clients with alcoholism frequently have pancreatic damage, this client is describing the results of liver damage. While clients with alcoholism frequently have brain damage, this client is describing the results of liver damage. Assessment Physiological Integrity Analysis Objective: 11-5 11.8 The client is withdrawing from opioids. Which symptom best describe(s) the results of the nurses assessment? Select all that apply. 1. Dilated pupils. 2. Diaphoresis. 3. Pinpoint pupils. 4. Hypotension. 5. Abdominal cramping and pain. Answer: 1, 2, 5 Rationale: Signs of opioid withdrawal include diaphoresis, restlessness, dilated pupils, hypertension, and abdominal cramps and pain. The pupils will be dilated during opioid withdrawal, but will appear pinpoint when the client is using opiods. The blood pressure will be elevated during opioid withdrawal, but will be decreased when the client is using opiods. Assessment Psychosocial Integrity Application Objective: 11-3

11.9 What is a priority outcome for the client who has chronic alcoholism with liver damage? 1. The client will switch to a safer drug, like a benzodiazepine. 2. The client will learn to drink more responsibly. 3. The client will keep all appointments with the doctor treating his liver damage. 4. The client will become involved in Alcoholics Anonymous (AA). Answer: 4 Rationale: Long-term management for alcohol abuse includes behavioral counseling and self-help groups like Alcoholics Anonymous (AA). The priority outcome, and a principle of Alcoholics Anonymous (AA), is complete abstinence from mood-altering substances so the client should not use benzodiazepines. Drinking more responsibly is not appropriate; the client must abstain from all alcohol. Keeping all medical appointments is a good outcome, but does not address the problem of the clients continued use of alcohol. Planning Physiological Integrity Analysis Objective: 11-6 11.10 The client is admitted to the in-patient substance abuse unit. She tells the nurse she has been buying yellow jackets (pentobarbital, {Nembutal}) on the street, but hasnt had any for a few days. What is the best plan by the nurse at this time? 1. Prepare to manage a withdrawal that will likely be minimal. 2. Prepare to manage a withdrawal that could be life-threatening. 3. Prepare to manage the depression and suicidal thoughts the client will have. 4. Prepare to do frequent room searches, as the clients friends will most likely bring drugs in for her. Answer: 2 Rationale: Barbiturates are central nervous depressant (CNS) drugs. Withdrawal symptoms resemble those of alcohol withdrawal, and may be life-threatening. Withdrawal from barbiturates will more likely be life-threatening, not minimal. Physical needs have priority over psychological needs, such as depression, in this case. Doing room searches is a good idea, but preparing for withdrawal is a higher priority. Planning Physiological Integrity Application Objective: 11-5 11.11 The client had been abusing cocaine for several years. Recently, the client snorted cocaine that was much purer than was thought, resulting in an overdose. The client died in the emergency department. What does the nurse recognize as the most likely cause of death? 1. Impurities in the cocaine 2. Bowel ischemia 3. Cardiac arrest 4. Rhabdomyolysis Answer: 3 Rationale: Overdose of cocaine can result in dysrhythmias, convulsions, stroke, or death due to cardiac and respiratory arrest. Impurities in the cocaine would not have resulted in the death of the client. Bowel ischemia would not occur with a cocaine overdose. Rhabdomyolysis would not occur with a cocaine overdose. Evaluation Physiological Integrity Application Objective: 11-5

11.12 The client has smoked a pack of cigarettes per day for twenty years. The client also takes oral contraceptives. In implementing a teaching plan, what is the most important information for the nurse to include? 1. The nicotine will decrease the effectiveness of your birth control pills. 2. You are at a higher risk for a heart attack than nonsmokers. 3. You are at a higher risk for emphysema than nonsmokers. 4. You are at a higher risk for developing diabetes than smokers who do not use birth control pills. Answer: 2 Rationale: Cardiovascular effects can be particularly serious in clients taking oral contraceptives if they also smoke. The risk of a fatal heart attack is five times greater in smokers who also use oral contraceptives than in nonsmokers. There is no evidence to support that nicotine decreases the effectiveness of oral contraceptives. Smokers are at higher risk for emphysema, but this has nothing do with the clients use of oral contraceptives. There is no evidence to support a correlation between diabetes, smoking, and oral contraceptives. Implementation Physiological Integrity Application Objective: 11-5 11.13 The client has been prescribed disulfiram (Antabuse) to discourage a return to drinking alcohol. The client tells the nurse that after stopping disulfiram (Antabuse) for a week, he returned to drinking alcohol. What will the nurse most likely assess in the client? 1. Headache, nausea and vomiting. 2. An absence of symptoms, as the drug was discontinued. 3. Severe hyperglycemia and dry skin. 4. Confusion and fine tremors. Answer: 1 Rationale: If alcohol is consumed while taking disulfiram (Antabuse), the client becomes violently ill within five to ten minutes. Symptoms include headache, shortness of breath, nausea, and vomiting. Alcohol sensitivity continues for up to two weeks after disulfiram (Antabuse) has been discontinued. Severe hypoglycemia and dry skin are not side effects of the combined use of alcohol and disulfiram (Antabuse). Confusion and fine tremors are not side effects of the combined use of alcohol and disulfiram (Antabuse). Assessment Physiological Integrity Application Objective: 11-6 11.14 The client tells the nurse that her 12-year-old child asks to use her nail polish remover several times a day. When her friends come to visit, this seems to occur more frequently. What is the best response by the nurse? 1. Your daughter may be huffing or rubbing the remover on her skin. 2. Your daughter may be huffing or drinking small amounts of the remover. 3. Your daughter may be huffing; that is really scary. 4. Your daughter may be huffing or inhaling the remover. Answer: 4 Rationale: Inhaling volatile chemicals, known as huffing is most prevalent in the 10to-12-year-old group. Virtually any organic compound can be huffed, including nail polish remover, spray paint, household glue, and gasoline. Huffing involves inhaling volatile chemicals, not rubbing them on the skin. Huffing involves inhaling volatile chemicals, not drinking them. Telling the mother that huffing is scary does not give her much information, and is an inappropriate response. Implementation Psychosocial Integrity

Application Objective: 11-5 11.15 The client is a 10-year-old child admitted to the emergency department after huffing gasoline. The physician suspects mild brain damage. What signs will the nurse teach the parents to observe for after they take the child home? 1. Irregular pulse, fainting, and anger 2. Slurred speech, memory loss, and personality changes 3. Depression, cold extremities, and dyspnea 4. Nausea, vomiting, and dizziness Answer: 2 Rationale: Children can die after a single episode of huffing a volatile chemical, or they may suffer brain damage. Brain damage may be manifested as slurred or slow speech, memory loss, or personality changes. Irregular pulse, fainting, and anger are not signs of brain damage. Depression, cold extremities, and dyspnea are not signs of brain damage. Nausea, vomiting, and dizziness are not signs of brain damage. Implementation Physiological Integrity Application Objective: 11-6 11.16 Which of the following profiles would have the greatest risk for developing a drug addiction? 1. A 70-year-old retired male with congestive heart failure who lives in his house in a large city (fixed income) 2. A 21-year-old male with insomnia who lives in a college dormitory (wealthy) 3. A 30-year-old female who is pregnant and lives in an apartment in a small town (lower middle class) 4. A 45-year-old female with diabetes who lives in a house in the country (middle class) Answer: 2 Rationale: The 21-year-old male has the most risk factors. He lives in a college dormitory, where peer pressure and drug availability are more likely. He also suffers from insomnia, which would likely encourage scheduled drug use. Finally, he is wealthy, enabling him to purchase drugs. The 70-year-old male has congestive heart failure, which generally does not require highly addictive drugs. Additionally, he is on a fixed income, which would make it more difficult to support a drug addiction. The 30-year-old female is also in a lower financial class, making it more difficult to support a drug addiction. Additionally, she is pregnant, and social norms generally are not supportive of drug use during pregnancy. The 45-year-old female might have the financial means to support a drug addiction but suffers from diabetes, which does not generally require addictive drug therapy. (pp. 104105) Comprehension Planning Health Promotion and Maintenance Objective: 11-1 11.17 When an individual wants to stop using a drug but cant, she would be suffering from: 1. Physical dependence.

2. Psychological dependence. 3. Substance dependence. 4. Withdrawal syndrome. Answer: 3 Rationale: The question does not indicate the presence or lack of symptoms. Therefore, the more general term substance dependence is the best choice. (p. 105) Knowledge Assessment Health Promotion and Maintenance Objective: 11-2 11.18 The nurse would expect to see which of the following withdrawal symptoms from an alcoholic patient? Tremors, anxiety, confusion, and delirium Abdominal pain, chills, pupil dilation, and lethargy Anxiety, seizures, hearing loss, and alopecia Lethargy, constipation, light sensitivity, and weight loss Answer: 3 Rationale: Common withdrawal symptoms associated with alcohol include: tremors, fatigue, anxiety, abdominal cramping, hallucinations, confusion, seizures, and delirium. (p. 106) Knowledge Assessment Physiological Integrity Objective: 11-3 11.19 A hospice patient has been receiving oral pain medication for several weeks. The patient started with 4 mg of the drug, and each week has had to increase the amount by 23 mg to obtain adequate pain relief. The nurse recognizes that the patient: 1. Has developed a tolerance to the drug. 2. Has developed a psychological addiction to the drug. 3. Has developed a physiologic addiction to the drug. 4. Has developed an immunity to the drug. Answer: 3 Rationale: Drug tolerance occurs when the body adapts to a substance after repeated administration. Although addictions are possible, the situation presented best describes drug tolerance, not addiction. Drug immunity is a term that is often confused with drug tolerance. Drug immunity is more appropriately used when discussing the immune system. (pp. 105107) Comprehension Assessment Physiological Integrity Objective: 11-4 11.20 Which of the following drugs is least likely to produce physical dependence or tolerance?

1. Morphine 2. Ethyl alcohol 3. Nicotine 4. Marijuana Answer: 4 Rationale: Although psychological dependence is very high with marijuana, it has minor-to-no withdrawal symptoms. (pp. 106109) Knowledge Planning Physiological Integrity Objective: 11-5 11.21 During a health history, the nurse should use therapeutic communication when asking about substance abuse. Which of the following is essential to establish a trusting nurseclient relationship? 1. Informing the patient that substance abuse is a sin 2. Ensuring that the patient's mother and father are at the bedside 3. Avoiding shocked facial expressions 4. Avoiding communicating disapproval of indicated substance abuse Answer: 3 Rationale: The nurse should be non-judgmental, but should firmly communicate disapproval of any indicated substance abuse. Informing the patient that substance abuse is a sin is being judgmental. Patients might be less likely to inform the nurse of a hidden substance abuse problem in the presence of family members. (p. 112) Comprehension Implementation Safe, Effective Care Environment Objective: 11-6 11.22 A patient suffering from tachycardia and palpitations would most likely be experiencing the signs of drug toxicity from which of the following? Marijuana Nicotine Benzodiazepines Alcohol Answer: 2 Rationale: Signs of nicotine toxicity include: heart palpitations, tachydysrhythmias, confusion, depression, and seizures. (p. 106) Knowledge Assessment Physiological Integrity Objective: 11-5