Question

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Answer 1

Correct Answers:

Determine the presence and degree of suicidal risk.

Rationale :

🔴 Safety is priority: According to Maslow’s hierarchy of needs and the ABC (Airway, Breathing, Circulation) + Safety principle, assessing for suicidal ideation is the highest priority in a client with depression, alcohol withdrawal, and recent major loss.

🔴 High-risk combination: Depression, substance withdrawal, and a recent significant stressor (job loss) greatly increase the risk of suicide.

🔴 Guides immediate care: Determining suicidal intent, plan, and means allows the nurse to implement urgent safety measures, such as one-to-one observation or hospitalization if needed.

🔴 Other interventions follow: Referrals, education, and support groups are important but are secondary to ensuring the client’s immediate safety.

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Answer 2

Correct Answers:

Methadone

Rationale :

🟢 Opioid withdrawal management: Methadone is a long-acting opioid agonist used to alleviate withdrawal symptoms and reduce opioid cravings in a controlled and medically supervised manner.

🟢 Prevents severe withdrawal: It helps stabilize the client by preventing acute withdrawal effects such as muscle aches, nausea, diarrhea, and irritability.

🟢 Part of maintenance therapy: Methadone can also be used for long-term opioid dependence treatment under strict regulation.

🟢 Other options not appropriate:

Disulfiram is for alcohol dependence,

Risperidone is an antipsychotic for schizophrenia,

Lithium carbonate is for bipolar disorder.

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Answer 3

Correct Answers:

2

Rationale :

Tablets to administer = Desired dose ÷ Available dose per tablet

150 mg ÷ 75 mg/tablet = 2 tablets

✅ Answer: 2 tablets

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Answer 4

Correct Answers:

I don't really have a problem with alcohol. I've just been having a streak of bad luck lately."

Rationale :

💠 Denial & rationalization: This statement reflects defense mechanisms where the client denies the severity of alcohol abuse and rationalizes it by blaming external circumstances ("bad luck").

💠 Common in addiction: Individuals with substance abuse issues often use denial or rationalization to avoid confronting reality and reduce feelings of guilt or shame.

💠 Blocks recovery: Such mechanisms prevent self-awareness and delay acceptance of treatment.

💠 Nursing approach: The nurse should use therapeutic communication to gradually help the client acknowledge the problem.

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Answer 5

Correct Answers:

Volunteering for overtime on a continual basis, avoiding having a witness to wasting narcotics, needing to be alone in the medication room when preparing medications.

Rationale :

🔴 Classic red flags: These behaviors are strongly associated with substance use disorder in healthcare workers, particularly diversion of controlled substances.

🔴 Pattern of opportunity-seeking: Volunteering for overtime and wanting to be alone in the medication room suggest attempts to gain unsupervised access to narcotics.

🔴 Avoiding accountability: Refusing to have a witness when wasting narcotics raises suspicion of medication diversion or tampering.

🔴 Managerial response: The nurse manager should follow institutional protocols, including reporting, observation, and possible drug testing, to ensure patient safety and staff accountability.

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Answer 6

Correct Answers:

"How do you feel about being discharged?"

Rationale :

🔷 Client-centered approach: This open-ended question encourages the client to express feelings about the transition, which may include anxiety, fear, or excitement.

🔷 Supports therapeutic closure: Discussing emotions before discharge helps process the ending of the therapeutic relationship appropriately.

🔷 Maintains professional boundaries: Unlike offering personal reassurance or promises, this response keeps the focus on the client’s experience.

🔷 Guides discharge planning: Understanding the client’s feelings can help address concerns or fears related to community reintegration.

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Answer 7

Correct Answers:

Education and interventions early in childhood when children are more inclined to change.

Rationale :

🟢 Early prevention is key: Introducing drug and alcohol education in early childhood is most effective because children are more receptive to guidance and less influenced by peer pressure at this stage.

🟢 Builds healthy habits: Early intervention promotes positive coping skills, decision-making, and resilience before risky behaviors develop.

🟢 Delays initiation of use: Preventive education before exposure to drugs or alcohol significantly reduces the likelihood of experimentation later in life.

🟢 Public health best practice: Early school-based programs are supported by research as a primary prevention strategy.

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Answer 8

Correct Answers:

Family history of addiction
Poor educational resources
Low self-esteem
Lack of support system

Rationale :

✅ Family history of addiction

🧬 Genetic predisposition: A family history of addiction increases the likelihood of developing substance use disorders due to genetic vulnerability.

👀 Environmental modeling: Children who grow up observing substance use at home may adopt these maladaptive coping behaviors.

🔄 Intergenerational influence: Exposure to such environments normalizes drug or alcohol use, increasing the risk of addiction later in life.

✅ Poor educational resources

📚 Limited knowledge: Lack of quality education leads to low awareness of substance abuse risks.

💼 Fewer opportunities: Poor education often correlates with economic hardship, increasing stress and risk for substance use as a coping mechanism.

🏫 Community factor: Schools with inadequate resources often lack preventive programs, leaving children vulnerable to experimentation.

✅ Low self-esteem

🧠 Psychological vulnerability: Low self-worth drives individuals to seek temporary relief through substances.

👥 Peer pressure susceptibility: Low self-esteem makes resisting peer influence more difficult, especially in adolescence.

🔄 Cycle of dependence: Substance use may worsen self-image, fueling a continuing cycle of abuse.

✅ Lack of support system

🤝 Social isolation risk: Without family or social support, individuals may turn to substances for comfort or companionship.

🚫 Recovery barriers: Lack of a support system hinders seeking help and maintaining sobriety.

🛡️ Protective factor absence: Support systems act as a protective barrier; their absence increases vulnerability to addiction.

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Answer 9

Correct Answers:

Having a learning disability
Substance uses within immediate family
Feeling unsafe at home
Fighting with peers at school

Rationale :

✅Having a learning disability

🧠 Academic struggles: Children with learning disabilities often experience low academic achievement, leading to frustration and poor self-esteem.

👥 Social difficulties: Struggling in school may result in peer rejection or bullying, increasing the likelihood of turning to substances to fit in or cope emotionally.

⚠️ Vulnerability: Learning challenges can make a child more vulnerable to negative peer influence and risky behaviors.

✅Substance use within immediate family

🏠 Modeling behavior: Children who grow up in homes where family members use substances are more likely to view substance use as acceptable or normal.

🧬 Genetic predisposition: A family history of substance abuse also increases the risk of addiction due to hereditary factors.

🔄 Environmental influence: Easy access to substances at home increases experimentation and early initiation.

✅Feeling unsafe at home

🚨 Emotional stress: Living in an unsafe environment (domestic violence, neglect, or abuse) can cause chronic stress and anxiety, leading to self-medicating with substances.

🧩 Coping mechanism: Children often seek temporary relief from emotional pain through drugs or alcohol.

❗ Psychological impact: An unsafe home disrupts healthy emotional development, increasing the risk for maladaptive coping strategies.

✅Fighting with peers at school

👊 Behavioral issues: Aggressive behavior and frequent fights may indicate poor impulse control and difficulty managing emotions.

🗨️ Peer rejection: Children who fight with peers may become socially isolated, making them more susceptible to joining negative peer groups involved in substance use.

⚠️ Early conduct issues: Behavioral problems in childhood are strong predictors of later risk-taking and substance abuse.

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Answer 10

Correct Answers:

They compulsively act on the urge to continue internet gaming and gambling even though they suffered negative consequences.

Rationale :

💎 Core feature of non-substance addiction: The defining characteristic of behavioral (non-substance) addictions, such as internet gaming disorder or gambling disorder, is the compulsive engagement in the behavior despite harmful consequences.

💎 Loss of control: The client’s inability to stop gaming or gambling despite job loss, financial ruin, and relationship breakdown reflects impaired control, a hallmark of addiction.

💎 Persistent cravings: The compulsive need to continue indicates psychological dependence similar to substance use disorders.

💎 Other options: Bankruptcy, depression, or lack of concern may be consequences or emotional responses, but compulsion despite harm is the key diagnostic criterion.

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QLexNursing

1 :
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

2 :
A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

3 :
A nurse is preparing to administer amitriptyline 150 mg PO. The amount available is amitriptyline 75 mg/ tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 :
The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?

5 :
A nurse manager is reviewing a recent client report related to a staff nurse. Which of the following behaviors by a nurse at work might be red flags for a substance use disorder?

6 :
A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

7 :
A public health nurse is working with a local school to implement programs for the prevention of drug and alcohol use disorder. The nurse should identify which of the following interventions is an effective strategy for preventing drug and alcohol use disorder in children?

8 :
A nurse is assisting the charge nurse to prepare for an in service with nursing staff to discuss substance use disorders. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)

9 :
A nurse is collecting data from a 12-year-old child. Which of the following assessment findings would indicate a high risk for developing substance abuse?
(Select All that Apply.)

QLexNursing

1 : A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

2 : A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

3 : A nurse is preparing to administer amitriptyline 150 mg PO. The amount available is amitriptyline 75 mg/ tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 : The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?

5 : A nurse manager is reviewing a recent client report related to a staff nurse. Which of the following behaviors by a nurse at work might be red flags for a substance use disorder?

6 : A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

7 : A public health nurse is working with a local school to implement programs for the prevention of drug and alcohol use disorder. The nurse should identify which of the following interventions is an effective strategy for preventing drug and alcohol use disorder in children?

8 : A nurse is assisting the charge nurse to prepare for an in service with nursing staff to discuss substance use disorders. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)

9 : A nurse is collecting data from a 12-year-old child. Which of the following assessment findings would indicate a high risk for developing substance abuse?(Select All that Apply.)

1 :
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

2 :
A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

3 :
A nurse is preparing to administer amitriptyline 150 mg PO. The amount available is amitriptyline 75 mg/ tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 :
The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?

5 :
A nurse manager is reviewing a recent client report related to a staff nurse. Which of the following behaviors by a nurse at work might be red flags for a substance use disorder?

6 :
A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

7 :
A public health nurse is working with a local school to implement programs for the prevention of drug and alcohol use disorder. The nurse should identify which of the following interventions is an effective strategy for preventing drug and alcohol use disorder in children?

8 :
A nurse is assisting the charge nurse to prepare for an in service with nursing staff to discuss substance use disorders. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)

9 :
A nurse is collecting data from a 12-year-old child. Which of the following assessment findings would indicate a high risk for developing substance abuse?
(Select All that Apply.)