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Chapter 23. Substance-Related and Addictive Disorders
Multiple Choice
1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
A. Risk for injury R/T central nervous system stimulation
B. Disturbed thought processes R/T tactile hallucinations
C. Ineffective coping R/T powerlessness over alcohol use
D. Ineffective denial R/T continued alcohol use despite negative consequences
ANS: A
The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T
central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors
of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating;
elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need:
Physiological Integrity: Reduction of Risk Potential
2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30minute period. Which is the best rationale for assessing this client for substance use disorder?
A. Narcotic pain medication is contraindicated for all clients with active substance-use problems.
B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to
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analgesics and require increased doses to achieve
effective pain control.
C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction.
D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam
(Ativan) dosage.
ANS: B
The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or
benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve
effective pain control. Cross-tolerance occurs when one drug lessens the clients response to another drug.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Physiological Integrity
3. On the first day of a clients alcohol detoxification, which nursing intervention should take priority?
A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
ANS: C
The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in
a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for
substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening
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effects of the rebound stimulation of the central nervous system that occurs during withdrawal.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
4. Which client statement indicates a knowledge deficit related to substance use?
A. Although its legal, alcohol is one of the most widely abused drugs in our society.
B. Tolerance to heroin develops quickly.
C. Flashbacks from LSD use may reoccur spontaneously.
D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.
ANS: D
The nurse should determine that the client has a knowledge deficit related to substance use when the client
compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have
potentially harmful effects. Cannabis is the second most widely abused drug in the United States.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Health Promotion and Maintenance
5. A lonely, depressed divorce has been self-medicating with cocaine for the past year. Which term should a
nurse use to best describe this individuals situation?
A. The individual is experiencing psychological addiction.
B. The individual is experiencing physical addiction.
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C. The individual is experiencing substance addiction.
D. The individual is experiencing social addiction.
ANS: A
The nurse should use the term psychological addiction to best describe this clients situation. A client is
considered to be psychologically addicted to a substance when there is an overwhelming desire to use a
substance in order to produce pleasure or avoid discomfort.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Psychosocial Integrity
6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant
during alcohol withdrawal?
A. Antagonist therapy
B. Deterrent therapy
C. Codependency therapy
D. Substitution therapy
ANS: D
A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent lifethreatening symptoms that occur because of the rebound reaction of the central nervous system.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
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Physiological Integrity: Pharmacological and Parenteral Therapies
7. A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility
after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate
for a nurse to discuss with the client during discharge teaching?
A. After discharge, the client will immediately attend 90 AA meetings in 90 days.
B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C. After discharge, the client will incorporate family in AA attendance.
D. After discharge, the client will seek appropriate deterrent medications through AA.
ANS: A
The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA
meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It
accepts alcoholism as an illness and promotes total abstinence as the only cure.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need:
Psychosocial Integrity
8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members
who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse
immediately report to the ED physician?
A. Antecubital bruising
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale
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D. Dehydration
ANS: B
The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly
report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol
withdrawal delirium and possible seizure activity on about the second or third day following cessation of
prolonged alcohol consumption.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Physiological Integrity: Reduction of Risk Potential
9. Which client statement demonstrates positive progress toward recovery from a substance use disorder?
A. I have completed detox and therefore am in control of my drug use.
B. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings.
C. As a church deacon, my focus will now be on spiritual renewal.
D. Taking those pills got out of control. It cost me my job, marriage, and children.
ANS: D
A client who takes responsibility for the consequences of substance use is making positive progress toward
recovery. This client would most likely be in the working phase of the counseling process, in which he or she
accepts the fact that substance use causes problems.
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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need:
Health Promotion and Maintenance
10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this
intervention?
A. To assess for emotional strength
B. To assess for Wernicke-Korsakoff syndrome
C. To assess for tachycardia
D. To assess for fine tremors
ANS: D
The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal
from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety,
elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
Physiological Integrity: Reduction of Risk Potential
11. Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment
reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor
skin turgor. What should be the priority nursing diagnosis?
A. Knowledge deficit
B. Fluid volume excess
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C. Imbalanced nutrition: less than body requirements
D. Ineffective individual coping
ANS: C
The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body
requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The
nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent
feedings of nonirritating foods.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need:
Physiological Integrity
12. A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect.
She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse
associate with a positive prognosis for this client?
A. Im not going to use heroin ever again. I know Ive got the willpower to do it this time.
B. I cannot control my use of heroin. Its stronger than I am.
C. Im going to get all my children back. They need their mother.
D. Once I deal with my childhood physical abuse, recovery should be easy.
ANS: B
A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss
of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over
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the substance.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need:
Psychosocial Integrity
13. A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she
states, I just need to work harder to get him there on time. Which is the appropriate nursing response?
A. Why do you assume responsibility for his behaviors?
B. Codependency is a typical behavior of spouses of alcoholics.
C. Your husband needs to deal with the consequences of his drinking.
D. Do you understand what the term enabler means?
ANS: C
The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of
recovery from codependency, the codependent person must begin to let go of the denial that problems exist or
that his or her personal capabilities are unlimited.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
Psychosocial Integrity
14. Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal
from benzodiazepines?
A. Haloperidol (Haldol) and fluoxetine (Prozac)
B. Carbamazepine (Tegretol) and donepezil (Aricept)
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C. Disulfiram (Antabuse) and lorazepam (Ativan)
D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)
ANS: D
The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin)
for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting
benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would
be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may
progress to seizure activity.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
15. During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if
my wife hadnt been nagging me all the time to get a job. She never did think that I was good enough for her.
How should a nurse interpret this statement?
A. The client is using denial by avoiding responsibility.
B. The client is using displacement by blaming his wife.
C. The client is using rationalization to excuse his alcohol dependence.
D. The client is using reaction formation by appealing to the group for sympathy.
ANS: C
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The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder.
Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by
making excuses for the behavior.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need:
Psychosocial Integrity
16. A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery
process, which outcome should the nurse expect the client to initially accomplish?
A. The client will identify one person to turn to for support.
B. The client will give up all old drinking buddies.
C. The client will be able to verbalize the effects of alcohol on the body.
D. The client will correlate life problems with alcohol use.
ANS: D
To promote the recovery process the nurse should expect that the client would initially correlate life problems
with alcohol use. Acceptance of the problem is the first step of the recovery process.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need:
Psychosocial Integrity
17. 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?
A. 50 mg/dL
B. 100 mg/dL
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C. 250 mg/dL
D. 300 mg/dL
ANS: B
The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs.
Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to
700 mg/dL.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Physiological Integrity
18. A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency
department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a
nurse expect this client to exhibit withdrawal symptoms?
A. Between 3 a.m. and 11 a.m.
B. Shortly after a 24-hour period
C. At the beginning of the third day
D. Withdrawal is individualized and cannot be predicted.
ANS: A
The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3
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a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction
in heavy and prolonged alcohol use.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Physiological Integrity: Reduction of Risk Potential
19. A client diagnosed with depression and substance use disorder 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?
A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
B. Sedative-hypnotics are expensive and have numerous side effects.
C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.
ANS: A
The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are
potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system
depressants are additive with one another and are capable of producing physiological and psychological
dependence.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
Physiological Integrity: Reduction of Risk Potential
20. A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past
year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis
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appropriately documents this problem?
A. Ineffective coping R/T unresolved anxiety AEB substance abuse
B. Anxiety R/T poor sleep AEB difficulty falling asleep
C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
D. Risk for injury R/T addiction to Librium
ANS: C
Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain
the desired effects originally produced by a lower dose.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
21. A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse
expect to assess?
A. Gross tremors, delirium, hyperactivity, and hypertension
B. Disorientation, peripheral neuropathy, and hypotension
C. Oculogyric crisis, amnesia, ataxia, and hypertension
D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension
ANS: A
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Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an
addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea,
vomiting, tachycardia, hallucinations, and seizures.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Physiological Integrity
22. A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency
department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous
vomiting. What may these symptoms indicate to the ED nurse?
A. Alcohol poisoning
B. Cardiovascular accident (CVA)
C. A reaction to disulfiram (Antabuse)
D. A reaction to tannins in the red wine
ANS: C
Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good
deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck,
respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
23. A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral).
Which is the most appropriate reply by the nurse?
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A. This medication will help you maintain your abstinence.
B. This medication will cause uncomfortable symptoms if you combine it with alcohol.
C. This medication will decrease the effect alcohol has on your body.
D. This medication will lower your risk of experiencing a complicated withdrawal.
ANS: A
Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of
abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.
KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological
Integrity: Pharmacological and Parenteral Therapies
24. A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol
relapse. Which information should the nurse include when teaching the client about this medication?
A. Only oral ingestion of alcohol will cause a reaction when taking this drug.
B. It is safe to drink beverages that have only 12% alcohol content.
C. This medication will decrease your cravings for alcohol.
D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug.
ANS: D
If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last
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for as long as 2 weeks.
KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological
Integrity: Pharmacological and Parenteral Therapies
25. Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?
A. Darken the room to reduce stimuli in order to prevent seizures.
B. Assess aggressive behaviors in order to intervene to prevent injury to self or others.
C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system.
D. Teach the negative effects of alcohol on the body.
ANS: B
Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness,
impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
Safe and Effective Care Environment
26. A client diagnosed with alcohol use disorder joins a community 12-step program and states, My life is
unmanageable. How should the nurse interpret this clients statement?
A. The client is using minimization as an ego defense.
B. The client is ready to sign an Alcoholics Anonymous contract for sobriety.
C. The client has accomplished the first of 12 NURSINGTB.COM
steps advocated by Alcoholics Anonymous.
D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.
ANS: C
The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit
powerlessness over alcohol and that their lives have become unmanageable.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need:
Psychosocial Integrity
27. In assessing a client with polysubstance abuse, the nurse should recognize that withdrawal from which
substance may require a life-saving emergency intervention?
A. Dextroamphetamine (Dexedrine)
B. Diazepam (Valium)
C. Morphine (Astramorph)
D. Phencyclidine (PCP)
ANS: B
If large doses of a central nervous system (CNS) depressant (such as Valium) are repeatedly administered over
a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be
quite severe, even leading to convulsions and death.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
Physiological Integrity: Reduction of Risk Potential
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28. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How
should the nurse further evaluate this possibility?
A. By asking directly if the client has ever had a problem with alcohol
B. By holistically assessing the client, using the CIWA scale
C. By using a screening tool such as the CAGE questionnaire
D. By referring the client for physician evaluation
ANS: C
The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with
alcohol. This questionnaire is composed of four simple questions. Scoring two or three yes answers strongly
suggests a problem with alcohol.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need:
Psychosocial Integrity
Multiple Response
29. Which of the following nursing statements exemplify important insights that will promote effective
intervention with clients diagnosed with substance use disorders? Select all that apply.
A. I am easily manipulated and need to work on this prior to caring for these clients.
B. Because of my fathers alcoholism, I need to examine my attitude toward these clients.
C. Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights.
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D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social
skills training.
E. I can fix clients diagnosed with substance use disorders as long as I truly care about them.
ANS: A, B, D
The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients
diagnosed with substance-abuse disorders. A deficit in this area may affect the nurses ability to establish
therapeutic relationships with these clients. A nurse who adopts the attitude that he or she can fix another
person may be struggling with codependency issues.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need:
Psychosocial Integrity
30. 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.
B. This condition leads to a rise in serum ammonia, resulting in impaired mental functioning.
C. In this condition, blood accumulates in the abdominal cavity.
D. Neomycin and lactulose are used in the treatment of this condition.
E. This condition is caused by the inability of the liver to convert ammonia to urea.
ANS: A, C
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The nursing instructor should understand that further teaching is needed if the nursing student states that a diet
rich in protein will promote hepatic healing or that this condition causes blood to accumulate in the abdominal
cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires
abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia
by means of neomycin or lactulose. This condition occurs in response to the inability of the liver to convert
ammonia to urea for excretion.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need:
Physiological Integrity
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