A client admitted with alcohol use disorder is to be discharged tomorrow but the nurse is concerned that codependency is likely to hinder the client's full recovery once discharged. What finding supports the nurse's concern?
Correct Answer Rationale: The finding that supports the nurse's concern about codependency is lying to siblings about the client's drinking. Codependency often involves enabling behaviors, where a family member protects the client from facing the consequences of their actions.
Question 2
A client with alcohol use disorder is scheduled for discharge tomorrow, and the nurse is concerned that codependent behaviors may negatively affect the client's recovery after leaving the hospital. Which of the following findings supports the nurse's concern?
Correct Answer Rationale: Covering for the client at work when hungover is a classic enabling/codependent behavior that prevents the client from facing the natural consequences of their alcohol use and delays recovery.
Question 3
The nurse is preparing to discharge a client with alcohol use disorder. The nurse is concerned about the potential for codependent behavior from the client's partner, which may impede the client's recovery. Which of the following behaviors would most support the nurse's concern?
Correct Answer Rationale: This statement suggests that the partner may be taking on an unhealthy caretaking role, believing that their constant involvement is necessary for the client's recovery. Codependency can hinder recovery when the family member becomes overly involved, enabling the client's behavior.
Question 4
A client who arrived on the unit a few hours ago is experiencing active alcohol withdrawal. What nursing intervention should the nurse prioritize?
Correct Answer Rationale: The priority nursing intervention for a client experiencing active alcohol withdrawal is to initiate seizure precautions. Alcohol withdrawal can lead to serious complications such as seizures, which can occur within the first 12 to 48 hours after the last drink.
Question 5
A client admitted to the hospital with alcohol use disorder begins to show signs of alcohol withdrawal, including tremors, increased heart rate, and irritability. What is the priority nursing intervention?
Correct Answer Rationale: Benzodiazepines, such as diazepam or lorazepam, are commonly used in alcohol withdrawal to prevent the progression of symptoms and reduce the risk of complications like seizures.
Question 6
A client with a history of alcohol use disorder is admitted to the medical unit after a fall. The client is disoriented, tremulous, and states, "I see bugs crawling on the wall." Vital signs include: Blood pressure 160/95 mmHg, heart rate 120 beats/minute, respiratory rate 22 breaths/minute, and temperature 38.2°C (100.8°F). What is the priority nursing intervention?
Correct Answer Rationale: The client's symptoms suggest alcohol withdrawal delirium (delirium tremens), which is a medical emergency. Seizure precautions and continuous monitoring are the priority to ensure safety and manage complications.
Question 7
The nurse on the unit receives report from the emergency department on a client experiencing alcohol withdrawal who is on the way to the unit. What medication should the nurse expect to administer to the client?
Correct Answer Rationale: The nurse should expect to administer Chlordiazepoxide to the client. This medication is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, as it helps to prevent seizures and reduces anxiety.
Question 8
A client is admitted to the hospital for alcohol withdrawal and the healthcare provider prescribes chlordiazepoxide. What is the primary purpose of this medication?
Correct Answer Rationale: The primary purpose of Chlordiazepoxide is to prevent seizures and reduce anxiety during alcohol withdrawal. It is a benzodiazepine that helps manage acute alcohol withdrawal symptoms.
Question 9
A client with alcohol use disorder is prescribed chlordiazepoxide to manage withdrawal symptoms. Which of the following is most important for the nurse to monitor while the client is receiving this medication?
Correct Answer Rationale: As a benzodiazepine, Chlordiazepoxide can cause sedation and respiratory depression, especially when used in high doses or in combination with other central nervous system depressants. Monitoring the client's level of sedation ensures early detection of any adverse effects.
Question 10
The nurse coming on the shift reads in the client's chart that the client has been experiencing symptoms of alcohol withdrawal. When the nurse assesses the client, what physiological assessment finding is the nurse likely to find?
Correct Answer Rationale: The nurse is likely to find an increased heart rate as a physiological assessment finding in a client experiencing alcohol withdrawal. Alcohol withdrawal can trigger the autonomic nervous system, leading to symptoms such as tachycardia.
Question 11
A client with alcohol use disorder is experiencing symptoms of alcohol withdrawal. The nurse expects the client to exhibit which of the following signs within the first 6 to 12 hours after the last drink?
Correct Answer Rationale: Tremors, anxiety, and sweating are common symptoms of alcohol withdrawal that typically appear within the first 6 to 12 hours after the last drink. Severe confusion, hallucinations, seizures, and delirium tremens occur later in more severe withdrawal.
Question 12
A client with a history of alcohol use disorder is admitted to the hospital. Twelve hours after admission, the nurse observes the client is anxious, diaphoretic, and tremulous. Which assessment finding is indicative of early alcohol withdrawal?
Correct Answer Rationale: Early alcohol withdrawal typically occurs within 6-24 hours of the last drink and is characterized by elevated vital signs (hypertension, tachycardia), anxiety, tremors, sweating, and nausea. Confusion, hallucinations, and seizures generally occur later in severe withdrawal.
Question 13
A client with a chronic history of alcohol abuse is brought to the emergency department. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dL (Normal range: 0 mg/dL). Among the health care provider's orders is a prescription for thiamine. What is the rationale for this intervention?
Correct Answer Rationale: The rationale for administering thiamine in this scenario is to prevent Wernicke-Korsakoff syndrome. This is a severe neurological disorder caused by thiamine (vitamin B1) deficiency, which is common in individuals with chronic alcohol abuse.
Question 14
A client with chronic alcohol use disorder is admitted to the hospital due to confusion, difficulty walking, and memory impairment. The healthcare provider orders thiamine supplementation. What is the rationale for this intervention?
Correct Answer Rationale: Thiamine supplementation is commonly prescribed to prevent Wernicke's encephalopathy in individuals with chronic alcohol use disorder. Alcohol impairs thiamine absorption and utilization.
Question 15
A client with a long history of alcohol use disorder is admitted for treatment and exhibits confusion, ataxia, and poor memory. The healthcare provider orders thiamine supplementation. What is the primary purpose of this treatment?
Correct Answer Rationale: The primary purpose of thiamine supplementation is to address the risk of vitamin B1 deficiency, which is common in individuals with chronic alcohol use disorder. Deficiency can lead to neurological issues such as confusion, ataxia, and memory problems.
Question 16
The charge nurse on an inpatient psychiatric floor is teaching a floor nurse about clinical manifestations of alcohol withdrawal. The charge nurse knows the floor nurse demonstrates understanding when the floor nurse lists which clinical manifestations?
Correct Answer Rationale: Tremors are a common manifestation of alcohol withdrawal, as the body reacts to the absence of alcohol. Bradycardia, hypotension, and constipation are not typical withdrawal symptoms.
Question 17
The nurse is caring for a client experiencing alcohol withdrawal. Which of the following clinical manifestations should the nurse expect in this client?
Correct Answer Rationale: Hypertension (increased blood pressure) is a common symptom of alcohol withdrawal, resulting from sympathetic nervous system activation. Hypothermia, muscle rigidity, and blurred vision are not typically seen during alcohol withdrawal.
Question 18
The nurse is caring for a client undergoing alcohol withdrawal. Which of the following symptoms would the nurse most likely observe in this client?
Correct Answer Rationale: Increased heart rate (tachycardia) is a common sign of alcohol withdrawal as the body reacts to the absence of alcohol and activates the sympathetic nervous system.
Question 19
Alcoholics Anonymous (AA) is a 12-step program to assist people to remain sober from alcohol through abstinence as the only cure. Which statement is correct regarding the concept of AA?
Correct Answer Rationale: AA views alcoholism as a disease, acknowledging individuals with this condition are not morally flawed but rather suffering from a chronic illness that requires ongoing management.
Question 20
The nurse is caring for a client who has a history of alcohol use disorder and expresses interest in Alcoholics Anonymous (AA). The client states, "I want to cut back on my drinking, but I don't think I need to quit completely." Based on the principles of AA, what is the most appropriate response by the nurse?
Correct Answer Rationale: AA's fundamental principle is complete abstinence from alcohol, not controlled or social drinking. The nurse should educate the client about this core AA principle.
Question 21
A client with alcohol use disorder that is taking disulfiram relapses and drinks a glass of wine. The client presents in the emergency department experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse should recognize these symptoms indicate which condition?
Correct Answer Rationale: These symptoms are indicative of a reaction to disulfiram. Disulfiram is a medication used to treat alcohol use disorder by inhibiting the enzyme aldehyde dehydrogenase. When alcohol is consumed while taking disulfiram, acetaldehyde builds up in the body, causing the observed reaction.
Question 22
A client taking disulfiram for alcohol use disorder arrives at the clinic with complaints of flushing, nausea, vomiting, and dizziness. The nurse recognizes that these symptoms are most likely due to which of the following?
Correct Answer Rationale: The symptoms described (flushing, nausea, vomiting, dizziness) are classic signs of a disulfiram-alcohol reaction, which occurs when a client taking disulfiram consumes alcohol or uses alcohol-containing products.
Question 23
A client who has been taking disulfiram as part of their recovery program comes to the emergency department complaining of severe headache, chest pain, palpitations, and shortness of breath. The nurse suspects that these symptoms are most likely related to which of the following?
Correct Answer Rationale: Severe headache, chest pain, palpitations, and shortness of breath are indicative of a serious disulfiram-alcohol reaction. This reaction can be life-threatening and occurs when a client consumes alcohol while taking disulfiram.