Substance Use Disorder
A client arrives in the emergency department after being found difficult to arouse. The nurse notes a respiratory rate of 7/min, oxygen saturation of 86%, pinpoint pupils, and cool skin. Which cue is most important for the nurse to recognize?
A. Respiratory depression with miosis strongly supports opioid toxicity. Airway and breathing can deteriorate rapidly, making this cue more urgent than the other possibilities.
A client admitted for major depression says, “There is no point in trying anymore.” Which hypothesis should the nurse address first?
A
Hopelessness is strongly associated with suicide risk. The nurse must assess suicidal thoughts, plan, intent, access to means, and protective factors before addressing lower-priority concerns.
A client has elevated mood, increased goal-directed activity, and decreased sleep for 5 days. Coworkers notice the change, but the client continues working and has no psychosis or marked impairment. Which interpretation is most appropriate?
B
Hypomania lasts at least 4 days, is observable, and represents a change from baseline without marked impairment, hospitalization, or psychosis. Those latter features would indicate mania.
A client is hyperventilating during a panic attack. Which action should the nurse take first?
B
Presence, calm communication, reduced stimulation, and coached breathing address severe anxiety safely. Detailed teaching is delayed until anxiety decreases; paper-bag rebreathing can cause hypoxia and is not recommended.
A client with bulimia nervosa reports weakness and palpitations after repeated vomiting. Which problem should the nurse prioritize?
A
Vomiting can cause hypokalemia and dysrhythmias. Possible cardiovascular instability takes priority over important but less immediate psychosocial problems.
Four hours after admission for alcohol withdrawal, a client becomes disoriented, reports seeing insects on the wall, and has a blood pressure of 178/104 mm Hg. Which problem should the nurse prioritize?
B
Hallucinations, marked hypertension, and disorientation suggest severe withdrawal with risk for seizures, aspiration, dysrhythmias, and death. Immediate physiologic safety precedes longer-term psychosocial needs.
A client taking phenelzine reports a sudden severe occipital headache and palpitations after eating aged cheese. Which action is the priority?
B
A severe headache and palpitations after tyramine exposure suggest hypertensive crisis, which requires immediate evaluation and treatment. Waiting may result in stroke or other end-organ injury.
A client taking lithium reports vomiting, coarse tremor, weakness, and unsteady gait after working outside in hot weather. Which interpretation is most appropriate?
B
Dehydration and sodium loss reduce lithium clearance and raise serum levels. GI symptoms, coarse tremor, weakness, and ataxia are toxicity cues requiring immediate action.
A veteran with PTSD reports nightmares, increasing alcohol use, social withdrawal, and the statement, “Everyone would be better off if I had not survived.” Which concern is the priority?
B
Survivor guilt, substance use, withdrawal, and perceived burdensomeness increase suicide risk. Direct assessment of thoughts, plan, intent, means, and protective factors is the immediate priority.
The nurse receives report on four clients. Which client should be assessed first?
B
A falling phosphate level during refeeding is an early cue of potentially fatal refeeding syndrome. The other clients need therapeutic support but are not showing immediate physiologic instability.
A client prescribed disulfiram says, “I switched to alcohol-free mouthwash, so I am safe.” Which response by the nurse is best?
B
Even small or hidden sources of alcohol can cause an acetaldehyde reaction. The client should check foods, medicines, toiletries, and topical products rather than altering the prescription independently.
A client taking sertraline develops agitation, diaphoresis, diarrhea, hyperreflexia, and a temperature of 39°C (102.2°F) after starting an over-the-counter cough medicine. Which complication should the nurse suspect?
A
Mental-status change, autonomic instability, GI symptoms, fever, and neuromuscular hyperactivity after serotonergic drug exposure are characteristic of serotonin syndrome.
The nurse receives report on four clients taking lithium. Which client should be assessed first?
C
Slurred speech and ataxia are neurologic toxicity findings and require immediate assessment. Mild thirst and fine tremor can occur at therapeutic levels; 0.9 mEq/L is within the commonly targeted acute therapeutic range.
A client reports feeling detached from the body and says the surroundings seem unreal, but reality testing remains intact. Which phenomenon should the nurse recognize?
A
Detachment from oneself or a sense that the environment is unreal, with intact reality testing, is characteristic of depersonalization/derealization.
A client with severe malnutrition begins nutritional rehabilitation. Two days later the client develops edema, weakness, and confusion, with a low phosphate level. Which complication should the nurse suspect?
A
Rapid electrolyte and fluid shifts after nutrition is restarted can produce hypophosphatemia, edema, neurologic changes, dysrhythmias, and cardiopulmonary failure. This is refeeding syndrome.
A hospitalized client reports drinking 8 to 10 alcoholic beverages daily and states the last drink was 10 hours ago. Which findings support emerging alcohol withdrawal? Select all that apply.
A, B, C, E
Alcohol withdrawal reflects CNS hyperactivity and commonly causes tremor, sweating, tachycardia, anxiety, insomnia, hypertension, and nausea. Pinpoint pupils and respiratory depression suggest opioid toxicity.
A client with depression has taken an SSRI for 1 week. Which findings require immediate follow-up? Select all that apply.
A, B, D
Giving away possessions, perceived burdensomeness, and an unexpected energy increase can signal escalating suicide risk. Mild early nausea and asking about onset require teaching but are not immediate danger cues.
Which findings in a client with bipolar disorder support acute mania? Select all that apply.
A, B, C, D, F
Decreased need for sleep, pressured speech, flight of ideas, risky behavior, and marked impairment are characteristic of mania. Psychomotor slowing is more consistent with depression.
The nurse plans care for a hospitalized client with severe OCD rituals. Which interventions are appropriate? Select all that apply.
A, C, D, E
Initial accommodation prevents overwhelming anxiety while trust develops; predictable structure, positive reinforcement, and gradual limits support treatment. Abrupt blocking and shaming are nontherapeutic.
A client with suspected anorexia nervosa is assessed. Which findings require prompt follow-up? Select all that apply.
A, B, C, D, F
Bradycardia, hypokalemia, hypothermia, orthostasis, and intense fear of weight gain are clinically significant cues. A dietary preference alone is not evidence of instability.
A client with severe alcohol use disorder is admitted for medically supervised withdrawal. Which interventions should the nurse anticipate including in the plan of care? Select all that apply.
A, B, C, E
Seizure precautions, structured assessment, reduced stimulation, and symptom-triggered medication promote safe withdrawal. Abrupt cessation of dependent sedatives can be dangerous, and thiamine should not be delayed in a client at risk for deficiency.
The nurse is planning care for a client with severe depression, psychomotor slowing, and minimal food intake. Which interventions are appropriate? Select all that apply.
A, C, E, F
Small meals, simple directions, supportive presence, and specific reinforcement address physiologic needs, safety, and impaired motivation. Activities should match energy level, and autonomy should be restored progressively.
Which discharge instructions are appropriate for a client taking lithium? Select all that apply.
A, B, C, E
Stable sodium and hydration help maintain a safe lithium level. Illness and sweating may cause dehydration, and ongoing serum, renal, and thyroid monitoring is essential. Doses should not be doubled and sodium should not be abruptly restricted.
A client repeatedly seeks emergency care for distressing physical symptoms despite negative evaluations. The client is highly anxious and spends hours researching diseases. Which approach is most appropriate?
B
Somatic symptoms and distress are real to the client. A consistent, matter-of-fact approach limits unnecessary testing while supporting emotional expression and functional goals.
Which interventions are appropriate for a client beginning inpatient treatment for an eating disorder? Select all that apply.
A, B, D, E
Consistency, objective monitoring, observation for compensatory behavior, and collaborative multidisciplinary planning promote safety and trust. Power struggles and appearance-focused praise can reinforce weight preoccupation.