Question 1 of 10
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When asked about alcohol consumption, which responses by a 35-year-old female prompts additional assessment?
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- “I drink three glasses of wine on Friday and Saturday evenings.”This response does not prompt additional assessment as it is less than four drinks per day and less than eight drinks weekly.
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- “I drink two glasses of wine every evening.”This response does prompt additional assessment. Although it is less than four drinks per day, it is more than eight drinks weekly.
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- “I drink one glass of wine every evening.”This response does not prompt additional assessment as it is less than four drinks per day and less than eight drinks weekly.
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- “I drink about six to seven glasses of wine weekly.”This response does not prompt additional assessment as it is less than eight drinks weekly.
Question 2 of 10
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A 28-year-old patient reports that he has a very stressful job and uses sleeping pills to help him fall asleep. What is the nurse’s best response?
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- “Do you feel groggy in the morning?”This may be important information but will not help determine the extent of the sleeping pill use.
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- “Do you get side effects from the sleeping pills?”This may be important information but will not help determine the extent of the sleeping pill use.
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- “What is your bedtime routine?”Although this is an important question to assess sleep hygiene, it is not related to the sleeping pill use.
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- “How many nights a week do you take sleeping pills?”This response will determine the extent of the sleeping pill use and will help assess if the use is a problem.
Question 3 of 10
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The nurse is concerned that a patient may be abusing alcohol. What questions should the nurse ask to assess risk factors?
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- “What age did you start drinking?”Early age of drinking is a risk factor for alcohol abuse.
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- “Does anyone in your family have a problem with alcohol?”Having a family member who abuses alcohol is a risk factor for alcohol abuse. It may be related to exposure and/or genetics.
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- “How many nights a week do you drink?”The amount of nights in a week that the patient drinks, assesses the extent of alcohol use but does not assess a risk factor.
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- “Do you feel a strong urge or craving for alcohol?”The question regarding assesses a characteristic of alcohol use but does not assess a risk factor.
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- “Do you have any mental health problems such as depression?”Mental health problems such as depression, anxiety, or bipolar disorder are a risk factor for alcohol abuse.
Question 4 of 10
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The nurse is examining the patient with suspected substance use. What eye examination components should the nurse include in the examination?
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- Pupil sizeAssessment of pupil size is part of the eye examination that the nurse should include in a patient with suspected substance abuse.
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- Corneal reflexAssessment of the corneal reflex is part of the eye examination that the nurse should include in a patient with suspected substance abuse.
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- Pupil reaction to lightAssessment of pupillary reaction to light is part of the eye examination that the nurse should include in a patient with suspected substance abuse.
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- Extraocular musclesAssessment of the extraocular muscles is not part of the eye examination that the nurse should include in a patient with suspected substance abuse.
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- Eyelid examinationAssessment of the eyelids is part of the eye examination that the nurse should include in a patient with suspected substance abuse.
Question 5 of 10
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In performing a head-to-toe assessment on a patient with suspected substance abuse, on what examination should the nurse focus?
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- Retinal examinationThe retinal examination is not part of the focused assessment.
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- BehaviorPatient behavior is part of the focused assessment.
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- Gait and balanceGait and balance are part of the focused assessment.
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- Nose and mouth examinationNose and mouth examination is part of the focused assessment.
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- Vital signsVital signs are part of the focused assessment.
Question 6 of 10
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The patient tells the nurse that she is a heavy drinker but has not had anything to drink for about a week. What findings will help the nurse determine if the patient is experiencing withdrawal delirium (“delirium tremens”)?
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- Coarse irregular tremorsCoarse irregular tremors are associated with withdrawal delirium.
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- BradycardiaTachycardia, not bradycardia, is associated with withdrawal delirium.
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- FeverFever is associated with withdrawal delirium.
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- SeizuresSeizures are associated with withdrawal delirium.
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- Enlarged liverAn enlarged liver suggests chronic alcohol use but is not a finding related to withdrawal delirium.
Question 7 of 10
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On examining a patient with suspected heroin use, which eye findings should the nurse expect?
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- Dilated pupilsWith heroin use, the pupils are constricted, not dilated.
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- Ptosis of lidPtosis of the eyelids is associated with heroin use.
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- NystagmusNystagmus is associated with marijuana and alcohol use but not heroin use.
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- Decreased corneal reflexDecreased corneal reflex is associated with heroin use.
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- Redness of scleraRedness of the sclera is associated with marijuana and alcohol use but not heroin use.
Question 8 of 10
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The patient presents with nausea, headache, malnutrition, flushed face, fever, and transient hallucinations. The nurse notes that the patient is agitated and suspects alcohol withdrawal. What finding does the nurse document as subjective data?
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- HallucinationsHallucinations are reported by the patient and are subjective data.
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- MalnutritionSigns of malnutrition are observed by the nurse and are objective data.
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- FeverFever is measured by the nurse and is objective data.
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- AgitationAgitation is observed by the nurse and is objective data. Agitation could be subjective data if it were reported by the patient.
Question 9 of 10
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What data should the nurse document as subjective data in a patient suspected of opiate use?
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- Euphoria followed by apathyEuphoria followed by apathy is reported by the patient and is subjective data.
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- Pinpoint pupilsPinpoint pupils are noted by the nurse and are objective data.
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- AmnesiaAmnesia is reported by the patient and is subjective data. Short-term memory impairment could be measured by the nurse and would be objective data.
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- Impaired family relationshipsImpaired family relationships is reported by the patient and is subjective data.
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- Depressed blood pressureBlood pressure is measured by the nurse and is objective data.
Question 10 of 10
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What data should the nurse document as objective data in a patient who reports marijuana use?
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- Dry mucous membraneDry mucous membrane is observed by the nurse and is objective data. If the patient reported having a dry mouth it would be subjective data.
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- Increased appetiteIncrease appetite is reported by the patient and is subjective data.
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- Slowed time perceptionSlowed time perception is experienced and reported by the patient and is subjective data.
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- Social withdrawalSocial withdrawal is reported by the patient and is subjective data.
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- Postural hypotensionBlood pressure and postural hypotension are measured by the nurse and are objective data.