Chapter 06: Substance Use Assessment My Nursing Test Banks

Chapter 06: Substance Use Assessment

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman?

a.

Dilated pupils, pacing, and psychomotor agitation

b.

Dilated pupils, unsteady gait, and aggressiveness

c.

Pupil constriction, lethargy, apathy, and dysphoria

d.

Constricted pupils, euphoria, and decreased temperature

ANS: A

A cocaine users appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The persons behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations.

DIF: Cognitive Level: Applying (Application) REF: p. 99

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

2. The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as:

a.

Hypertension.

b.

Ventricular fibrillation.

c.

Bradycardia.

d.

Mitral valve prolapse.

ANS: A

Even moderate drinking leads to hypertension and cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning. Ventricular fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol.

DIF: Cognitive Level: Applying (Application) REF: p. 89

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

3. The nurse is conducting a class on alcohol and the effects of alcohol on the body. How many standard drinks (each containing 14 grams of alcohol) per day in men are associated with increased deaths from cirrhosis, cancers of the mouth, esophagus, and injuries?

a.

2

b.

4

c.

6

d.

8

ANS: B

In men, alcohol consumption of at least four standard drinks per day is associated with increased deaths from liver cirrhosis, cancers of the mouth, esophagus and other areas, and deaths from injuries and other external causes.

DIF: Cognitive Level: Understanding (Comprehension) REF: pp. 89-90

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

4. During a session on substance abuse, the nurse is reviewing statistics with the class. For persons aged 12 years and older, which illicit substance was most commonly used?

a.

Crack cocaine

b.

Heroin

c.

Marijuana

d.

Hallucinogens

ANS: C

In persons age 12 years and older who reported using during the past month, marijuana (hashish) was the most commonly used illicit drug reported.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 90

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

5. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, How many drinks a day is safe for my baby? The nurses best response is:

a.

You should limit your drinking to once or twice a week.

b.

Its okay to have up to two glasses of wine a day.

c.

As long as you avoid getting drunk, you should be safe.

d.

No amount of alcohol has been determined to be safe during pregnancy.

ANS: D

No amount of alcohol has been determined to be safe for pregnant women. The potential adverse effects of alcohol use on the fetus are well known; women who are pregnant should be screened for alcohol use, and abstinence should be recommended.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 92

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

6. When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult?

a.

Increased muscle mass

b.

Decreased liver and kidney functioning

c.

Decreased blood pressure

d.

Increased cardiac output

ANS: B

Decreased liver and kidney functioning increases the bioavailability of alcohol in the blood for longer periods. Aging people experience decreased muscle mass (not increased), which also increases the alcohol concentration in the blood because the alcohol is distributed to less tissue over time. Blood pressure and cardiac output are not factors regarding bioavailability.

DIF: Cognitive Level: Applying (Application) REF: p. 92

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

7. During an assessment, the nurse asks a female patient, How many alcoholic drinks do you have a week? Which answer by the patient would indicate at-risk drinking?

a.

I may have one or two drinks a week.

b.

I usually have three or four drinks a week.

c.

Ill have a glass or two of wine every now and then.

d.

I have seven or eight drinks a week, but I never get drunk.

ANS: D

For women, having seven or more drinks a week or three or more drinks per occasion is considered at-risk drinking, according to the National Institute on Alcohol Abuse and Alcoholism.

DIF: Cognitive Level: Applying (Application) REF: p. 91

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

8. The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, Yes, Ive used marijuana at parties with my friends. What is the next question the nurse should ask?

a.

Who are these friends?

b.

Do your parents know about this?

c.

When was the last time you used marijuana?

d.

Is this a regular habit?

ANS: C

If a patient admits to the use of illicit substances, then the nurse should ask, When was the last time you used drugs? and How much did you take that time? The other questions may be considered accusatory and are not conducive to gathering information.

DIF: Cognitive Level: Applying (Application) REF: p. 94

MSC: Client Needs: Health Promotion and Maintenance

9. The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time?

a.

Record the results of the assessment, and notify the physician on call.

b.

State, You are drinking more than is medically safe. I strongly recommend that you quit drinking, and Im willing to help you.

c.

State, It appears that you may have a drinking problem. Here is the telephone number of our local Alcoholics Anonymous chapter.

d.

Give the patient information about a local rehabilitation clinic.

ANS: B

If an assessment has determined that the patient has at-risk drinking behavior, then the nurse should give a short but clear statement of assistance and concern. Simply giving out a telephone number or referral to agencies may not be enough.

DIF: Cognitive Level: Applying (Application) REF: p. 95

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

10. A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4 C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance?

a.

Alcohol

b.

Heroin

c.

Crack cocaine

d.

Sedatives

ANS: B

Withdrawal symptoms of opiates, such as heroin, are similar to the clinical picture of influenza and include symptoms such as dilated pupils, lacrimation, runny nose, tachycardia, fever, restlessness, muscle and joint pains, and other symptoms. (Withdrawal symptoms from alcohol, cocaine, and sedatives are described in Table 6-7.)

DIF: Cognitive Level: Applying (Application) REF: p. 99

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

11. The nurse is reviewing aspects of substance abuse in preparation for a seminar. Which of these statements illustrates the concept of tolerance to an illicit substance? The person:

a.

Has a physiologic dependence on a substance.

b.

Requires an increased amount of the substance to produce the same effect.

c.

Requires daily use of the substance to function and is unable to stop using it.

d.

Experiences a syndrome of physiologic symptoms if the substance is not used.

ANS: B

The concept of tolerance to a substance indicates that the person requires an increased amount of the substance to produce the same effect. Abuse indicates that the person needs to use the substance daily to function, and the person is unable to stop using it. Dependence is an actual physiologic dependence on the substance. Withdrawal occurs when cessation of the substance produces a syndrome of physiologic symptoms.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 91

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. A patient with a known history of heavy alcohol use has been admitted to the ICU after he was found unconscious outside a bar. The nurse closely monitors him for symptoms of withdrawal. Which of these symptoms may occur during this time? Select all that apply.

a.

Bradycardia

b.

Coarse tremor of the hands

c.

Transient hallucinations

d.

Somnolence

e.

Sweating

ANS: B, C, E

Symptoms of uncomplicated alcohol withdrawal start shortly after the cessation of drinking, peak at the second day, and improve by the fourth or fifth day. Symptoms include coarse tremors of the hands, tongue, and eyelids; anorexia; nausea and vomiting; autonomic hyperactivity (e.g., tachycardia, sweating, elevated blood pressure); and transient hallucinations, among other symptoms (see Table 6-7).

DIF: Cognitive Level: Applying (Application) REF: p. 96

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

2. A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years and wants to stop cold turkey. He asks the nurse, What symptoms can I expect if I do this? Which of these symptoms should the nurse share with the patient as possible symptoms of nicotine withdrawal? Select all that apply.

a.

Headaches

b.

Hunger

c.

Sleepiness

d.

Restlessness

e.

Nervousness

f.

Sweating

ANS: A, B, D, E

Symptoms of nicotine withdrawal include vasodilation, headaches, anger, irritability, frustration, anxiety, nervousness, awakening at night, difficulty concentrating, depression, hunger, impatience, and the desire to smoke (see Table 6-7).

DIF: Cognitive Level: Applying (Application) REF: p. 99

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

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