Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 11

Chapter 11: Substance Abuse
Test Bank
MULTIPLE CHOICE
1. Which assessment finding would alert the nurse to ask the patient about alcohol use?
a. Low blood pressure
b. Decreased heart rate
c. Elevated temperature
d. Abdominal tenderness
ANS: D
Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in
patients with chronic alcohol use. The other problems are not associated with alcohol abuse.
DIF: Cognitive Level: Apply (application) REF: 160

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
2. The nurse plans postoperative care for a patient who smokes a pack of cigarettes daily. Which
goal should the nurse include in the plan of care for this patient?
a. Improve sleep
b. Enhance appetite
c. Decrease diarrhea
d. Prevent sore throat
ANS: A
Insomnia is a characteristic of nicotine withdrawal. Diarrhea, sore throat, and anorexia are not
symptoms associated with nicotine withdrawal.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
3. A young adult patient scheduled for an annual physical examination arrives in the clinic
smelling of cigarette smoke and carrying a pack of cigarettes. Which action will the nurse plan
to take?
a. Urge the patient to quit smoking as soon as possible.
b. Avoid confronting the patient about smoking at this time.
c. Wait for the patient to start the discussion about quitting smoking.
d. Explain that the cold turkey method is most effective in stopping smoking.
ANS: A
Current national guidelines indicate that health care professionals should urge patients who
smoke to quit smoking at every encounter. The other actions will not help decrease the
patients health risks related to smoking.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
4. A patient admitted to the hospital after an automobile accident is alert and does not appear to
be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11 mg%).
Which action by the nurse is most appropriate?
a. Avoid the use of IV fluids.
b. Maintain the patient on NPO status.
c. Administer acetaminophen for headache.
d. Monitor frequently for anxiety, hyperreflexia, and sweating.
ANS: D
The patients assessment data indicate probable physiologic dependence on alcohol, and the
patient is likely to develop acute withdrawal such as anxiety, hyperreflexia, and sweating,
which could be life threatening. Acetaminophen is not recommended because it is metabolized
by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated patients to
prevent Wernickes encephalopathy, and there is no indication that the patient should be NPO.
DIF: Cognitive Level: Apply (application) REF: 160-161

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
5. An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing

emergency surgery. What will the nurse expect the patient to need during the perioperative
period?
a. An increased dose of the general anesthetic medication
b. Frequent monitoring for bleeding and respiratory complications
c. Interventions to prevent withdrawal symptoms within a few hours
d. Stimulation every hour to prevent prolonged postoperative sedation
ANS: B
Patients who are intoxicated at the time of surgery are at increased risk for problems with
bleeding and respiratory complications such as aspiration. In an intoxicated patient, a lower
dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is likely
to occur later in the postoperative course because the medications used for anesthesia,
sedation, and pain will delay withdrawal symptoms. The patient should be monitored
frequently for oversedation but does not need to be stimulated.

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
6. A patient with alcohol dependence is admitted to the hospital with back pain following a fall.
Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action
by the nurse is most appropriate?
a. Insert an IV line and infuse fluids.
b. Promote oral intake to 3000 mL/day.
c. Provide a quiet, well-lit environment.
d. Administer opioids to provide sedation.
ANS: C
The patients symptoms suggest acute alcohol withdrawal, and a quiet and well-lit
environment will help decrease agitation, delusions, and hallucinations. There is no indication
that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent
withdrawal. IV lines are avoided whenever possible.

7. A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which
statement by the patient indicates a willingness to stop alcohol use?
a. I am older and wiser now, and I think I can change my drinking behavior.
b. Alcohol has never bothered my stomach before. I think I likely have the flu.
c. My drinking is affecting my stomach, but some drugs will help me feel better.
d. People say that I drink too much, but I really feel pretty good most of the time.
ANS: A
The statement I am older and wiser now, and I know I can change my drinking behavior
indicates the patient expresses willingness to stop alcohol use and an initial commitment to
changing alcohol intake behaviors. In the remaining statements, the patient recognizes that
alcohol use is the reason for the gastritis but is not yet willing to make a change.

8. A patient who smokes a pack of cigarettes daily develops tachycardia and irritability on the
second day after abdominal surgery. What is the nurses best action at this time?
a. Escort the patient outside where smoking is allowed.
b. Move the patient to a private room and allow smoking.
c. Tell the patient that this is a good time to quit smoking.
d. Request a prescription for a nicotine replacement agent.
ANS: D
Nicotine replacement agents should be prescribed for patients who smoke and are hospitalized
to avoid withdrawal symptoms. Allowing the patient to smoke encourages ongoing smoking.
Urging the patient to quit smoking is appropriate, but the first action should be to obtain
appropriate medications to prevent withdrawal symptoms.

9. A patient who is admitted to the hospital for wound debridement admits to using fentanyl
(Sublimaze) illegally. What finding does the nurse expect?
a. Nausea and diarrhea
b. Tremors and seizures
c. Lethargy and disorientation
d. Delusions and hallucinations
ANS: A
Symptoms of opioid withdrawal include gastrointestinal symptoms such as nausea, vomiting,
and diarrhea. The other symptoms are seen during withdrawal from other substances such as
alcohol, sedative-hypnotics, or stimulants.
DIF: Cognitive Level: Understand (comprehension) REF: 163

10. A newly admitted patient complains of waking frequently during the night. The nurse
observes the patient wearing a nicotine patch (Nicoderm CQ) on the right upper arm. Which
action is best for the nurse to take?
a. Question the patient about use of the patch at night.
b. Suggest that the patient go to bed earlier in the evening.
c. Ask the health care provider about prescribing a sedative drug for nighttime use.
d. Remind the patient that the benefits of the patch outweigh the short-term
insomnia.
ANS: A
Insomnia can occur when nicotine patches are used all night. This can be resolved by
removing the patch in the evening. The other actions may be helpful in improving the patients
sleep, but the initial action should be to ask about nighttime use of the patch and suggest
removal of the patch at bedtime.

11. During physical assessment of a patient who has frequent nosebleeds, the nurse finds nasal
sores and necrosis of the nasal septum. The nurse should ask the patient specifically about the
use of which drug?
a. Heroin
b. Cocaine
c. Tobacco
d. Marijuana
ANS: B
When cocaine is inhaled, it causes ischemia of the nasal septum, leading to nasal sores and
necrosis. These symptoms are not associated with the use of heroin, tobacco, or marijuana.

12. A patient admitted with shortness of breath and chest pain who is a pack-a-day smoker tells
the nurse, I am just not ready to quit smoking yet. Which response by the nurse is best?
a. This would be a really good time to quit.
b. Your smoking is the cause of your chest pain.
c. What health problems do you think smoking has caused?
d. Are you familiar with the various nicotine replacement options?
ANS: C
The patient is in the precontemplation stage of change, and the nurses role is to assist the
patient to become motivated to quit. The current Clinical Practice Guidelines indicate that the
nurse should ask the patient to identify any negative consequences from smoking. The
responses This would be a really good time to quit and Your smoking is the cause of your
chest pain express judgmental feelings by the nurse and are not likely to motivate the patient.
Providing information about the various nicotine replacement options would be appropriate
for a patient who has expressed a desire to quit smoking.

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
13. A disoriented and agitated patient comes to the emergency department and admits using
methamphetamine. Vital signs are blood pressure 162/98, heart rate 142 and irregular, and
respirations 32. Which action by the nurse is most important?
a. Reorient the patient at frequent intervals.
b. Monitor the patients electrocardiogram (ECG) and vital signs.
c. Keep the patient in a quiet and darkened room.
d. Obtain a health history including prior drug use.
ANS: B
The priority is to ensure physiologic stability given that methamphetamine use can lead to
complications such as myocardial infarction. The other actions are also appropriate but are not
of as high a priority.

14. A 75-year-old patient is admitted for pancreatitis. Which tool would be the most appropriate
for the nurse to use during the admission assessment?
a. Drug Abuse Screening Test (DAST-10)
b. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
c. Screening Test-Geriatric Version (SMAST-G)
d. Mini-Mental State Examination
ANS: C
Because the abuse of alcohol is a common factor associated with the development of
pancreatitis, the first assessment step is to screen for alcohol use using a validated screening
questionnaire. The SMAST-G is a short-form alcoholism screening instrument tailored
specifically to the needs of the older adult. If the patient scores positively on the SMAST-G,
then the CIWA-Ar would be a useful tool for determining treatment. The DAST-10 provides
more general information regarding substance use. The Mini-Mental State Examination is
used to screen for cognitive impairment.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
15. An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a
refill of the prescription 1 month before the alprazolam should need to be refilled. Which
response by the nurse is best?
a. The prescription cannot be refilled for another month. What happened to all of
your pills?
b. Do you have any muscle cramps and tremors if you dont take the medication
frequently?
c. I am concerned that you may be overusing the Xanax. Lets make an appointment
for you to see the doctor.
d. I will ask the doctor to prescribe a few more pills, but you will not be able to get
any more for another month.
ANS: C
The patient should be assessed for problems that are causing overuse of alprazolam , such as
anxiety or memory loss. The other responses by the nurse will not allow for the needed
assessment and possible referral for support services or treatment of drug dependence.

16. A patient who has inhaled cocaine is admitted to the emergency department with palpitations
and shortness of breath. What should the nurse do first?
a. Obtain a 12-lead echocardiogram (ECG).
b. Start oxygen at 4 L/minute.
c. Draw blood for drug screening.
d. Infuse normal saline at 100 mL/hr.
ANS: B
The priority here is to ensure that oxygenation is adequate. The other orders also should be
accomplished as soon as possible but are not the first priority.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
17. The nurse cares for an agitated patient who was admitted to the emergency department after
taking a hallucinogenic drug and attempting to jump from a third-story window. Which
nursing diagnosis should the nurse assign as the highest priority?
a. Risk for injury related to altered perception
b. Ineffective health maintenance related to drug use
c. Powerlessness related to loss of behavioral control
d. Ineffective denial related to lack of control of life situation
ANS: A
Although all the diagnoses may be appropriate for the patient, the highest priority is to address
the patients immediate risk for injury.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
18. A young adult patient comes to the emergency department with severe chest pain and
agitation. Which action should the nurse take first?
a. Give naloxone (Narcan) IV.
b. Ask about any use of stimulant drugs.
c. Assess orientation to person, place, and time.
d. Check blood pressure, pulse, and respirations.
ANS: D
The patient has symptoms consistent with the use of cocaine or amphetamines and is at risk
for fatal tachydysrhythmias or complications of hypertension such as stroke or myocardial
infarction. The nurse also will ask about drug use and assess orientation, but these are not the
priority actions. Naloxone may be given if the patient develops symptoms of central nervous
system (CNS) depression, but this patients current symptoms indicate stimulant use.

MSC: NCLEX: Psychosocial Integrity
19. A patient presents to the emergency department with a blood alcohol concentration (BAC) of
0.18%. After reviewing the medication orders, which drug should the nurse administer first?
a. Thiamine (vitamin B1) 100 mg daily
b. Lorazepam (Ativan) 1 mg as needed
c. Folic acid (Vitamin B9) 0.4 mg daily
d. Dextrose 5% in 0.45 saline at 125 mL/hr
ANS: A
Thiamine is given to all patients with alcohol intoxication to prevent Wernickes
encephalopathy. Because Wernickes encephalopathy can be precipitated by the administration
of glucose solutions, the thiamine should be given before (or concurrently with) the 5%
dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated
BAC. Folic acid may also be administered, but is not as important as thiamine.

MSC: NCLEX: Psychosocial Integrity
20. Which information is most important for the nurse to report to the health care provider about
a patient who has been using varenicline (Chantix)?
a. The patient continues to smoke a few cigarettes every day.
b. The patient complains of headaches that occur almost daily.
c. The patient complains of new-onset sadness and depression.
d. The patient says, I have decided that I am not ready to quit.
ANS: C
Adverse effects of varenicline include depression and attempted suicide. The patients
symptoms require immediate assessment and discontinuation of the drug. The other
information will also be reported, but it does not indicate any life-threatening problems
associated with the medication.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
21. A patient who has a history of ongoing opioid abuse is hospitalized for surgery. After a visit
by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which
prescribed medication will the nurse administer immediately?
a. Naloxone (Narcan)
b. Diazepam (Valium)
c. Clonidine (Catapres)
d. Methadone (Dolophine)
ANS: A
The patients assessment indicates an opioid overdose, and naloxone should be given to
prevent respiratory arrest. The other medications may be used to decrease symptoms
associated with opioid withdrawal but would not be appropriate for an overdose.

22. After receiving change-of-shift report on four patients who are undergoing substance abuse
treatment, which patient will the nurse assess first?
a. A patient who has just arrived for alcohol abuse treatment and states that the last
drink was 3 hours ago
b. A patient who is agitated and experiencing nausea, occasional vomiting, and
diarrhea while withdrawing from heroin
c. A patient who has tremors secondary to benzodiazepine withdrawal and whose last
benzodiazepine use was 4 days ago
d. A patient who is being treated for cocaine addiction and is irritable and
disoriented, with a pulse rate of 112 beats/minute
ANS: C
The patients tremors indicate risk for seizures and possible cardiac/respiratory arrest, which
can occur with withdrawal from sedative-hypnotics. The greatest risk for these complications
is during days three to five after stopping the drug. Opioid and stimulant withdrawal is
uncomfortable, but not life threatening. Symptoms of alcohol withdrawal do not occur until 4
to 6 hours after the last drink.
DIF: Cognitive Level: Analyze (analysis) REF: 163

OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
23. After the nurse receives report, which patient should the nurse assess first?
a. Patient who has a respiratory rate of 14 after overdosing on oxycodone
(OxyContin)
b. Patient admitted with cocaine use who has an irregular heart rate of 142
beats/minute
c. Patient who is experiencing hallucinations and extreme anxiety after the use of
marijuana
d. Patient with a history of daily alcohol use who is complaining of insomnia and
diaphoresis
ANS: B
Because the patient with cocaine use has symptoms suggestive of a possible fatal
dysrhythmia, this patient should be assessed immediately. The other patients should also be
seen as soon as possible, but their clinical manifestations do not suggest that life-threatening
complications may be occurring.

OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning
24. Which nursing activity can the nurse delegate to unlicensed assistive personnel (UAP) who
are working in a family practice clinic?
a. Make referrals to community substance abuse treatment centers.
b. Teach patients about the use of prescribed nicotine replacement products.
c. Administer and score the Alcohol Use Disorders Identification Test (AUDIT).
d. Obtain patient histories regarding alcohol, tobacco, and other substance abuse.
ANS: C
No clinical judgment is needed to administer the AUDIT, which is a written questionnaire that
is given to patients for self-administration and scored based on patient answers. Making
appropriate referrals, patient teaching, and obtaining a patient history all require critical
thinking and RN education and scope of practice.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
OTHER
1. A patient is admitted to the emergency department for treatment of a possible opioid overdose.
Rank the nursing activities in the correct order from first activity to last activity. (Put a
comma and a space between each answer choice [A, B, C, D, E]).
a. Initiate IV access.
b. Take a health history.
c. Obtain a toxicology screen.
d. Administer naloxone (Narcan).
e. Provide respiratory support with a bag-valve mask.
ANS:
E, A, D, C, B
Maintenance of the airway is the first priority for patients with possible depressant overdose.
Opioid antagonists are given before toxicology testing is done because reversal of the opioid
will prevent respiratory arrest. However, this will require IV access. The toxicology report
will help guide further treatment for possible multiple substance ingestions. The health history
will guide care after the initial emergency treatment phase.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 11

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Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 11

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Chapter 11: Substance Abuse

DIF: Cognitive Level: Apply (application) REF: 160

DIF: Cognitive Level: Apply (application) REF: 156

DIF: Cognitive Level: Apply (application) REF: 156

DIF: Cognitive Level: Apply (application) REF: 160-161

5. An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing

DIF: Cognitive Level: Apply (application) REF: 155

DIF: Cognitive Level: Apply (application) REF: 162

DIF: Cognitive Level: Apply (application) REF: 156

DIF: Cognitive Level: Apply (application) REF: 156-157

DIF: Cognitive Level: Understand (comprehension) REF: 163

DIF: Cognitive Level: Apply (application) REF: 159

DIF: Cognitive Level: Apply (application) REF: 155

DIF: Cognitive Level: Apply (application) REF: 156-157

DIF: Cognitive Level: Apply (application) REF: 161

DIF: Cognitive Level: Apply (application) REF: 167

DIF: Cognitive Level: Apply (application) REF: 163

DIF: Cognitive Level: Apply (application) REF: 164

DIF: Cognitive Level: Apply (application) REF: 160

DIF: Cognitive Level: Apply (application) REF: 164

DIF: Cognitive Level: Apply (application) REF: 160

DIF: Cognitive Level: Apply (application) REF: 157

DIF: Cognitive Level: Apply (application) REF: 164

DIF: Cognitive Level: Analyze (analysis) REF: 163

DIF: Cognitive Level: Analyze (analysis) REF: 164

DIF: Cognitive Level: Apply (application) REF: 165

DIF: Cognitive Level: Analyze (analysis) REF: 164

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