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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 50
Question 1
Type: MCSA
When gathering data on clients with substance abuse and dependency, the nurse will expect to find the most
common coping mechanism in clients, families, and nurses working with them to be:
1. Projection.
2. Sublimation.
3. Denial.
4. Rationalization.
Correct Answer: 3
Rationale 1: The families of clients with substance dependency and abuse often use denial to cope with the
client's problem, and are likely to make excuses for the client, or attempt to explain away his behavior as normal.
Rationale 2: The families of clients with substance dependency and abuse often use denial to cope with the
client's problem, and are likely to make excuses for the client, or attempt to explain away his behavior as normal.
Rationale 3: The families of clients with substance dependency and abuse often use denial to cope with the
client's problem, and are likely to make excuses for the client, or attempt to explain away his behavior as normal.
Rationale 4: The families of clients with substance dependency and abuse often use denial to cope with the
client's problem, and are likely to make excuses for the client, or attempt to explain away his behavior as normal.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss issues and terms related to substance abuse and dependency.
Question 2
Type: MCSA
The nurse receives a call from the spouse of a client with chronic alcoholism. The spouse reports that the client
has been having hallucinations, and just had a brief seizure. The nurse directs the spouse to:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Give him a glass of alcohol and see if he gets better immediately.


2. Question him about any medications he might have taken.
3. Call the physician and inform her of the client's condition.
4. Call EMS and have him taken to the hospital Emergency Department.
Correct Answer: 4
Rationale 1: This client likely is experiencing alcohol withdrawal and delirium tremens. The client requires
immediate medical intervention, and should be taken to the local Emergency Department by ambulance to prevent
further symptoms. Administering alcohol would reduce the symptoms but also would not support recovery.
Rationale 2: This client likely is experiencing alcohol withdrawal and delirium tremens. The client requires
immediate medical intervention, and should be taken to the local Emergency Department by ambulance to prevent
further symptoms. Administering alcohol would reduce the symptoms but also would not support recovery.
Rationale 3: This client likely is experiencing alcohol withdrawal and delirium tremens. The client requires
immediate medical intervention, and should be taken to the local Emergency Department by ambulance to prevent
further symptoms. Administering alcohol would reduce the symptoms but also would not support recovery.
Rationale 4: This client likely is experiencing alcohol withdrawal and delirium tremens. The client requires
immediate medical intervention, and should be taken to the local Emergency Department by ambulance to prevent
further symptoms. Administering alcohol would reduce the symptoms but also would not support recovery.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Learning Outcome: Identify effects of alcohol and other CNS depressants.
Question 3
Type: MCSA
The nurse is caring for a client withdrawing from alcohol, and calls the physician to report the client's symptoms
anticipating an order for what classification of medication?
1. Benzodiazepines
2. Sedative hypnotic
3. Disulfiram (Antabuse)
4. Hydrochloride (Narcan)
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 1
Rationale 1: Benzodiazepines are the most frequently ordered classification of medication for treating alcohol
withdrawal because they are most effective.
Rationale 2: Benzodiazepines are the most frequently ordered classification of medication for treating alcohol
withdrawal because they are most effective.
Rationale 3: Benzodiazepines are the most frequently ordered classification of medication for treating alcohol
withdrawal because they are most effective.
Rationale 4: Benzodiazepines are the most frequently ordered classification of medication for treating alcohol
withdrawal because they are most effective.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify treatments and nursing interventions for clients with problems related to substance
abuse and dependency.
Question 4
Type: MCSA
When assessing clients who have developed early chronic alcoholism, the nurse anticipates finding:
1. Esophageal pain.
2. Right upper quadrant pain.
3. Diabetes mellitus.
4. Esophageal varices.
Correct Answer: 1
Rationale 1: Some of the earliest symptoms of chronic alcoholism are GI symptoms such as esophageal pain,
because alcohol causes esophagitis by inflaming the esophageal lining, exacerbated by frequent vomiting.
Rationale 2: Some of the earliest symptoms of chronic alcoholism are GI symptoms such as esophageal pain,
because alcohol causes esophagitis by inflaming the esophageal lining, exacerbated by frequent vomiting.
Rationale 3: Some of the earliest symptoms of chronic alcoholism are GI symptoms such as esophageal pain,
because alcohol causes esophagitis by inflaming the esophageal lining, exacerbated by frequent vomiting.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: Some of the earliest symptoms of chronic alcoholism are GI symptoms such as esophageal pain,
because alcohol causes esophagitis by inflaming the esophageal lining, exacerbated by frequent vomiting.
Global Rationale:
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe effects of commonly abused substances.
Question 5
Type: MCSA
The nurse is caring for a client diagnosed with alcoholic hepatic encephalopathy, and provides dietary teaching for
the client and spouse. The nurse determines dietary teaching was understood when the spouse states she will
prepare which of the following meals?
1. Steak, baked apple, deviled egg, and milk
2. Potato soup, mixed green salad, chocolate chip cookie, and iced tea
3. Tuna salad sandwich, potato chips, and vanilla custard
4. Toasted cheese sandwich, baked potato, and milk
Correct Answer: 2
Rationale 1: Hepatic encephalopathy is caused by accumulation of ammonia due to the damaged liver's inability
to metabolize protein. Treatment includes reducing protein intake, and the diet including potato soup, mixed green
salad, chocolate chip cookie, and iced tea would be lowest in protein while providing adequate calories and
nutrition to a client whose nutritional status has likely been adversely affected by alcoholism.
Rationale 2: Hepatic encephalopathy is caused by accumulation of ammonia due to the damaged liver's inability
to metabolize protein. Treatment includes reducing protein intake, and the diet including potato soup, mixed green
salad, chocolate chip cookie, and iced tea would be lowest in protein while providing adequate calories and
nutrition to a client whose nutritional status has likely been adversely affected by alcoholism.
Rationale 3: Hepatic encephalopathy is caused by accumulation of ammonia due to the damaged liver's inability
to metabolize protein. Treatment includes reducing protein intake, and the diet including potato soup, mixed green
salad, chocolate chip cookie, and iced tea would be lowest in protein while providing adequate calories and
nutrition to a client whose nutritional status has likely been adversely affected by alcoholism.
Rationale 4: Hepatic encephalopathy is caused by accumulation of ammonia due to the damaged liver's inability
to metabolize protein. Treatment includes reducing protein intake, and the diet including potato soup, mixed green
salad, chocolate chip cookie, and iced tea would be lowest in protein while providing adequate calories and
nutrition to a client whose nutritional status has likely been adversely affected by alcoholism.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: Identify treatments and nursing interventions for clients with problems related to substance
abuse and dependency.
Question 6
Type: MCSA
The nurse working in the Emergency Department gets a call that a client with a suspected overdose of narcotics is
in route to the facility. The nurse best prepares for the client's arrival by setting up:
1. A tracheotomy set available for immediate use.
2. An amphetamine ready to administer stat on admission.
3. Naloxone hydrochloride (Narcan) ready to administer.
4. An EKG machine and a technician on standby.
Correct Answer: 3
Rationale 1: Administration of naloxone hydrochloride (Narcan) competes for binding sites with narcotics, and
will reverse the effects quickly, so the nurse would obtain the medication and have it ready when the provider
prescribes it.
Rationale 2: Administration of naloxone hydrochloride (Narcan) competes for binding sites with narcotics, and
will reverse the effects quickly, so the nurse would obtain the medication and have it ready when the provider
prescribes it.
Rationale 3: Administration of naloxone hydrochloride (Narcan) competes for binding sites with narcotics, and
will reverse the effects quickly, so the nurse would obtain the medication and have it ready when the provider
prescribes it.
Rationale 4: Administration of naloxone hydrochloride (Narcan) competes for binding sites with narcotics, and
will reverse the effects quickly, so the nurse would obtain the medication and have it ready when the provider
prescribes it.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: !NP>Intervention
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Identify treatments and nursing interventions for clients with problems related to substance
abuse and dependency.
Question 7
Type: MCSA
The nurse and client determine that which of the following would be the best long-term goal for the client with a
substance dependency? The client will:
1. Promise to abstain from the use of any substance to deal with problems.
2. Identify two acceptable means of solving problems other than substances.
3. Cut substance use in half and gradually decrease it to little or no use.
4. Agree to make restitution to those people who have been harmed.
Correct Answer: 2
Rationale 1: Clients with substance dependency often use the substance to help them cope with problems.
Helping the client identify other acceptable means of solving problems is an important long-term goal for this
client.
Rationale 2: Clients with substance dependency often use the substance to help them cope with problems.
Helping the client identify other acceptable means of solving problems is an important long-term goal for this
client.
Rationale 3: Clients with substance dependency often use the substance to help them cope with problems.
Helping the client identify other acceptable means of solving problems is an important long-term goal for this
client.
Rationale 4: Clients with substance dependency often use the substance to help them cope with problems.
Helping the client identify other acceptable means of solving problems is an important long-term goal for this
client.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify treatments and nursing interventions for clients with problems related to substance
abuse and dependency.
Question 8
Type: MCSA
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

The nurse caring for a client with an eating disorder interprets which of the following statements made by the
client as indicating progress toward meeting treatment goals?
1. "Eating alone has helped me gain control over my eating disorder."
2. "I have begun to feel very guilty when I don't eat the right amount."
3. "I have made a list of my positive attributes and accomplishments."
4. "My friends like the way I look now, and think I have made progress."
Correct Answer: 3
Rationale 1: Clients with eating disorders often have unrealistic views of themselves and have low self-esteem.
Helping the client to inventory her strengths and attributes will assist in improving her self-image, and this will
positively impact her food choices.
Rationale 2: Clients with eating disorders often have unrealistic views of themselves and have low self-esteem.
Helping the client to inventory her strengths and attributes will assist in improving her self-image, and this will
positively impact her food choices.
Rationale 3: Clients with eating disorders often have unrealistic views of themselves and have low self-esteem.
Helping the client to inventory her strengths and attributes will assist in improving her self-image, and this will
positively impact her food choices.
Rationale 4: Clients with eating disorders often have unrealistic views of themselves and have low self-esteem.
Helping the client to inventory her strengths and attributes will assist in improving her self-image, and this will
positively impact her food choices.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: Discuss treatment and nursing care for clients with eating disorders.
Question 9
Type: MCSA
The nurse explains the philosophy of Alcoholics Anonymous to the recovering alcoholic client as which of the
following?
1. A fellowship of people who share their experience, strength, and hope with each other that they might solve
their common problem and help others to recover from alcoholism

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

2. Through the use of a 12-step program, the members will develop a greater belief in God and recover from
alcoholism.
3. Help people to stop using alcohol and cure their addiction while advocating for recovering alcoholics through
the passage of legislation.
4. The primary purpose of Alcoholics Anonymous is to stay sober and help other alcoholics achieve sobriety.
Correct Answer: 1
Rationale 1: The philosophy of Alcoholics Anonymous and other 12-step programs is that people can recover
from alcoholism by sharing with others and following the 12 steps of the program. They are not affiliated with
any particular religious organization, and do not promote God, but rather a spiritual belief that there is something
greater than the self. They do not promote cures for alcoholism because they believe that once an alcoholic,
always an alcoholic, but instead emphasize recovery. While the primary purpose is to stay sober and help others
achieve sobriety, this is their purpose, not their philosophy. Other 12-step programs are based on this same
philosophy.
Rationale 2: The philosophy of Alcoholics Anonymous and other 12-step programs is that people can recover
from alcoholism by sharing with others and following the 12 steps of the program. They are not affiliated with
any particular religious organization, and do not promote God, but rather a spiritual belief that there is something
greater than the self. They do not promote cures for alcoholism because they believe that once an alcoholic,
always an alcoholic, but instead emphasize recovery. While the primary purpose is to stay sober and help others
achieve sobriety, this is their purpose, not their philosophy. Other 12-step programs are based on this same
philosophy.
Rationale 3: The philosophy of Alcoholics Anonymous and other 12-step programs is that people can recover
from alcoholism by sharing with others and following the 12 steps of the program. They are not affiliated with
any particular religious organization, and do not promote God, but rather a spiritual belief that there is something
greater than the self. They do not promote cures for alcoholism because they believe that once an alcoholic,
always an alcoholic, but instead emphasize recovery. While the primary purpose is to stay sober and help others
achieve sobriety, this is their purpose, not their philosophy. Other 12-step programs are based on this same
philosophy.
Rationale 4: The philosophy of Alcoholics Anonymous and other 12-step programs is that people can recover
from alcoholism by sharing with others and following the 12 steps of the program. They are not affiliated with
any particular religious organization, and do not promote God, but rather a spiritual belief that there is something
greater than the self. They do not promote cures for alcoholism because they believe that once an alcoholic,
always an alcoholic, but instead emphasize recovery. While the primary purpose is to stay sober and help others
achieve sobriety, this is their purpose, not their philosophy. Other 12-step programs are based on this same
philosophy.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Discuss the philosophy of the 12.step programs for treatment of substance abuse.
Question 10
Type: MCMA
The nurse caring for a client admitted to the substance abuse unit for narcotic withdrawal observes the adolescent
children of the client when they visit, and notes family dysfunction. The nurse talks with the teens, and could best
help them by saying: (Select all that apply.)
Standard Text: Select all that apply.
1. "Your mother has a problem with alcohol, but you are not blame for this. It was her choice to drink, not yours."
2. "You might consider attending Al-Anon to obtain support from others who have parents who are alcoholics."
3. "You are not alone in this. Many children and teens have alcoholic parents, and they face some of the same
problems you are dealing with."
4. "How does it make you feel when you find your mother has been drinking?"
5. "You should go about leading your own life, and not let your mother's drinking problems affect your life."
Correct Answer: 1,2,4
Rationale 1: The nurse can best help these adolescents deal with the mother's substance abuse by pointing out that
they are not responsible for the choices the mother made, directing them to Ala-Teen (not Al-Anon, which is for
adult spouses and significant others) for support and help, and questioning the teens to learn about their feelings
and coping mechanisms. It is not possible for the adolescents not to be affected by an alcoholic mother, so this is
an unreasonable expectation.
Rationale 2: The nurse can best help these adolescents deal with the mother's substance abuse by pointing out that
they are not responsible for the choices the mother made, directing them to Ala-Teen (not Al-Anon, which is for
adult spouses and significant others) for support and help, and questioning the teens to learn about their feelings
and coping mechanisms. It is not possible for the adolescents not to be affected by an alcoholic mother, so this is
an unreasonable expectation.
Rationale 3: The nurse can best help these adolescents deal with the mother's substance abuse by pointing out that
they are not responsible for the choices the mother made, directing them to Ala-Teen (not Al-Anon, which is for
adult spouses and significant others) for support and help, and questioning the teens to learn about their feelings
and coping mechanisms. It is not possible for the adolescents not to be affected by an alcoholic mother, so this is
an unreasonable expectation.
Rationale 4: The nurse can best help these adolescents deal with the mother's substance abuse by pointing out that
they are not responsible for the choices the mother made, directing them to Ala-Teen (not Al-Anon, which is for
adult spouses and significant others) for support and help, and questioning the teens to learn about their feelings
and coping mechanisms. It is not possible for the adolescents not to be affected by an alcoholic mother, so this is
an unreasonable expectation.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 5: The nurse can best help these adolescents deal with the mother's substance abuse by pointing out that
they are not responsible for the choices the mother made, directing them to Ala-Teen (not Al-Anon, which is for
adult spouses and significant others) for support and help, and questioning the teens to learn about their feelings
and coping mechanisms. It is not possible for the adolescents not to be affected by an alcoholic mother, so this is
an unreasonable expectation.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss the philosophy of the 12.step programs for treatment of substance abuse.
Question 11
Type: MCSA
While working on an orthopedic unit of an acute care facility, the nurse's level of suspicion regarding substance
dependency would be heightened if a peer made which of the following comments?
1. "Why don't you go to lunch and I'll give your client something for pain."
2. "I went out with my friends last night and got so drunk on two drinks."
3. "I think Mr. Mathews in room 212 is a drug abuser, because he's always asking for something for pain."
4. "I have a urinary tract infection, and I've had to go to the bathroom every 20 minutes."
Correct Answer: 1
Rationale 1: The nurse who frequently offers to administer narcotics to other nurses' clients raises the suspicion
of possible substance dependency, but this is not conclusive proof, and should not be acted upon until further
information is obtained that indicates substance use. The nurse who felt drunk after two drinks is unlikely to have
a problem, because tolerance increases with repeated use. The nurse talking about Mr. Mathews has broken client
confidentiality, and needs more education about pain management, but does not cause suspicion about substance
dependency. Urinary tract infections do cause frequent trips to the bathroom, and it is unlikely someone going to
the bathroom every 20 minutes is taking a narcotic that frequently.
Rationale 2: The nurse who frequently offers to administer narcotics to other nurses' clients raises the suspicion
of possible substance dependency, but this is not conclusive proof, and should not be acted upon until further
information is obtained that indicates substance use. The nurse who felt drunk after two drinks is unlikely to have
a problem, because tolerance increases with repeated use. The nurse talking about Mr. Mathews has broken client
confidentiality, and needs more education about pain management, but does not cause suspicion about substance
dependency. Urinary tract infections do cause frequent trips to the bathroom, and it is unlikely someone going to
the bathroom every 20 minutes is taking a narcotic that frequently.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: The nurse who frequently offers to administer narcotics to other nurses' clients raises the suspicion
of possible substance dependency, but this is not conclusive proof, and should not be acted upon until further
information is obtained that indicates substance use. The nurse who felt drunk after two drinks is unlikely to have
a problem, because tolerance increases with repeated use. The nurse talking about Mr. Mathews has broken client
confidentiality, and needs more education about pain management, but does not cause suspicion about substance
dependency. Urinary tract infections do cause frequent trips to the bathroom, and it is unlikely someone going to
the bathroom every 20 minutes is taking a narcotic that frequently.
Rationale 4: The nurse who frequently offers to administer narcotics to other nurses' clients raises the suspicion
of possible substance dependency, but this is not conclusive proof, and should not be acted upon until further
information is obtained that indicates substance use. The nurse who felt drunk after two drinks is unlikely to have
a problem, because tolerance increases with repeated use. The nurse talking about Mr. Mathews has broken client
confidentiality, and needs more education about pain management, but does not cause suspicion about substance
dependency. Urinary tract infections do cause frequent trips to the bathroom, and it is unlikely someone going to
the bathroom every 20 minutes is taking a narcotic that frequently.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe the appropriate response when substance abuse issues impair a colleague at work.
Question 12
Type: MCSA
The nurse assesses an 18-year-old female client who is 5 feet, 10 inches tall and weighs 110 pounds. The nurse
finds the client has well developed muscles, damage and discoloration of the teeth, mild dehydration, and
metabolic alkalosis, and suspects the possibility of:
1. Binge eating disorder with excessive use of laxatives.
2. Purging-type bulimia nervosa.
3. Anorexia nervosa with inadequate caloric intake.
4. Nonpurging-type bulimia nervosa.
Correct Answer: 2
Rationale 1: The discoloration of the teeth and metabolic alkalosis in a healthy adolescent would be highly
suspicious of possible purging-type bulimia nervosa. Exercise level is difficult to determine because even normal
activity levels can build well defined muscles. Anorexia nervosa would not explain the findings of teeth
discoloration.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: The discoloration of the teeth and metabolic alkalosis in a healthy adolescent would be highly
suspicious of possible purging-type bulimia nervosa. Exercise level is difficult to determine because even normal
activity levels can build well defined muscles. Anorexia nervosa would not explain the findings of teeth
discoloration.
Rationale 3: The discoloration of the teeth and metabolic alkalosis in a healthy adolescent would be highly
suspicious of possible purging-type bulimia nervosa. Exercise level is difficult to determine because even normal
activity levels can build well defined muscles. Anorexia nervosa would not explain the findings of teeth
discoloration.
Rationale 4: The discoloration of the teeth and metabolic alkalosis in a healthy adolescent would be highly
suspicious of possible purging-type bulimia nervosa. Exercise level is difficult to determine because even normal
activity levels can build well defined muscles. Anorexia nervosa would not explain the findings of teeth
discoloration.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify three major types of eating disorders.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.