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TB-Chapter 06 Substance Use Assessment
Health Assessment (James Madison University)
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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)
80
Chapter 06: Substance Use Assessment
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)
MSC: Client Needs: Physiologic Integrity: Physiologic
Adaptation
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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)
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?
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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)
a.
2
b.
4
c.
6
d.
8
81
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)
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
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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)
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.
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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)
82
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)
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 alcoholNURSINGTB.COM
is distributed to less tissue over time. Blood pressure and
cardiac output are not factors regarding bioavailability.
DIF: Cognitive Level: Applying (Application)
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)
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)
83
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)
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.
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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)
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?
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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)
a.
Alcohol
b.
Heroin
c.
Crack cocaine
d.
Sedatives
84
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.
DIF: Cognitive Level: Applying (Application)
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.
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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)
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
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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)
d.
Somnolence
e.
Sweating
85
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.
DIF: Cognitive Level: Applying (Application)
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
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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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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