1026 UNIT XIX Mental Health Disorders of the Adult Client

I. Dual diagnoses P R AC T I C E Q U E S T I O N S
1. Som etim es the use of alcoh ol and drugs m asks
underlying psychiatric pathology. 883. The hom e health nurse visits a client at hom e
2. Psychiatric pathology m ay also be precipitated and determ ines that the client is dependent
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on drugs. During the assessm ent, which action
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by substance use and abuse.
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3. When psychiatric disorders and substance abuse should the nurse take to plan appropriate nursing
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are present together, it is often referred to as dual care?
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diagnosis. 1. Ask the client why he started taking illegal drugs.
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4. Separating psychiatric diagnosis from substance 2. Ask the clien t about the am ount of drug use and
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dependence can be done only over tim e after a its effect.
sustain ed period of abstinence. 3. Ask the client how long he thought that he could
J. Addiction and abuse in health care profession als: take drugs without som eone finding out.
Suspicious signs 4. Not ask any question s for fear that the client is
1. Frequently reportin g that drugs have been in denial and will throw the nurse out of
wasted without being witnessed by another the hom e.
nurse
2. Reporting adm inistering m axim um dosages of 884. Which interventions are m ost approp riate for car-
controlled substances to clients when other nurses ing for a client in alcohol withdrawal? Select all
do not adm inister the m axim um dose th at apply.
3. A variance in usual pain relief in the absence of a 1. Monitor vital signs.
chan ge in dosage or frequen cy of adm inistration 2. Provide a safe environ m ent.
in their clien ts 3. Address hallucinations therapeutically.
4. Work pattern s include the following: Always 4. Provide stim ulation in the environm ent.
volunteering to carry narcotic (opioids) keys 5. Provide reality orientation as appropriate.
(or other opioid access devices per agency proce- 6. Maintain NPO (nothing by m outh) status.
dure); choosing shifts in which less supervision
is present; choosing work areas where the use 885. The nurse determ ines that the wife of an alcoholic
of controlled substances is high, such as critical client is benefiting from attending an Al-Anon
care units, operating room , anesthesia, and group if the nurse hears the wife m ake which
traum a units. statem ent?
5. Nurses have a professional and eth ical obligation 1. “I no longer feel that I deserve the beatings m y
to report im paired co-workers. husband inflicts on m e.”
6. Most impaired nurses are able to return to work 2. “My attendance at the m eetings has helped m e
through the State Board of Nursing assistance and to see that I provoke m y husban d’s violence.”
monitoring programs; such programs usually 3. “I enjoy attending the m eetings because they get
require strict adherence to clearly stated rules and m e out of the house and away from m y
regular reports and drug screens. husband.”
4. “I can tolerate m y husban d’s destructive behav-
iors now that I know they are com m on am on g
CRITICAL THINKING What Should You Do? alcoholics.”
Answer: The nurse should immediately contact the health
care provider if signs of alcohol withdrawal delirium occur, 886. A hospitalized client with a history of alcoh ol
and the nurse should follow agency protocol using specified abuse tells the nurse, “I am leavin g now. I have
assessment scales. One-to-one supervision needs to be pro- to go. I don’t want any m ore treatm ent. I have
vided to ensure safety. The nurse should provide care in a thin gs that I have to do right away.” The client
nonjudgmental manner and monitor vital signs and neuro- has not been discharged and is scheduled for an
logical signs (every 15 minutes). The environment should im portant diagnostic test to be perform ed in
be quiet and nonstimulating, and a family member should 1 hour. After the nurse discusses the client’s con-
be encouraged to stay with the client to minimize anxiety. cerns with the client, the client dresses and begins
The nurse should orient the client frequently, explain all treat- to walk out of the hospital room . What action
ments and procedures in a quiet and simple manner, initiate should the nurse take?
seizure precautions, and administer sedating or anticonvul- 1. Call the nursing supervisor.
sant medication as prescribed. In addition, the nurse should 2. Call security to block all exit areas.
provide small, frequent, high-carbohydrate foods (administer 3. Restrain the client until the health care provider
antiemetic before meals as needed). (HCP) can be reached.
Reference: Stuart (2013), p. 454. 4. Tell the client that the client cannot return to
this hospital again if the client leaves now.
 CHAPTER 70 Addictions 1027

887. The nurse is preparing to perform an adm ission 890. The nurse is m onitoring a hospitalized client who
assessm ent on a client with a diagnosis of bulim ia abuses alcoh ol. Which findings should alert the
nervosa. Which assessm ent findings should the nurse to the potential for alcoh ol withdrawal
nurse expect to note? Select all th at apply. delirium ?

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1. Dental decay 1. Hypotension , ataxia, hunger

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2. Moist, oily skin 2. Stupor, lethargy, m uscular rigidity

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3. Loss of tooth enam el 3. Hypotension, coarse hand trem ors, lethargy

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4. Electrolyte im balances 4. Hypertension , chan ges in level of conscious-

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5. Body weight well below ideal range ness, hallucinations

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888. The nurse is caring for a fem ale client who was 891. The spouse of a client adm itted to the m ental
adm itted to the m ental health unit recently for health unit for alcohol withdrawal says to the
anorexia nervosa. The nurse enters the client’s nurse, “I should get out of this bad situation.”
room and notes that the client is engaged in rigor- Which is the m ost helpful response by the nurse?
ous push-ups. Which nursing action is m ost 1. “Wh y don’t you tell your spouse about this?”
approp riate? 2. “What do you find difficult about this situation ?”
1. Interrupt the client and weigh her im m ediately. 3. “This is not the best tim e to m ake that decision .”
2. Interrupt the client and offer to take her for 4. “I agree with you. You should get out of this
a walk. situation.”
3. Allow the client to com plete her exercise
program .
892. Aclient with anorexia nervosa is a m em ber of a pre-
4. Tell the client that she is not allowed to exercise
discharge support group. The client verbalizes that
rigorously.
she would like to buy som e new clothes, but her
finances are lim ited. Group m em bers have brought
889. A client with a diagnosis of anorexia nervosa, who
som e used clothes to the client to replace the cli-
is in a state of starvation , is in a 2-bed room . A
ent’s old clothes. The client believes that the new
newly adm itted client will be assigned to this cli-
clothes are m uch too tight and has reduced her cal-
ent’s room . Which client would be the best choice
orie intake to 800 calories daily. How should the
as a room m ate for the client with anorexia
nurse evaluate this behavior?
nervosa?
1. Norm al beh avior
1. A client with pneum onia
2. Evidence of the client’s disturbed body im age
2. A client undergoing diagnostic tests
3. Regression as the client is m oving toward the
3. A client who thrives on m anaging oth ers
com m un ity
4. A client who could benefit from the client’s
4. Indicative of the client’s am bivalence about hos-
assistance at m ealtim e
pital discharge

AN S W E R S Priority Concepts: Addiction; Com m unication

References: Keltner, Steele (2015), pp. 80–81; Stuart (2013),
883. 2 p. 226.
Ra tiona le: Whenever the nurse carries out an assessm ent for a
client who is dependent on drugs, it is best for the nurse to 884. 1, 2, 3, 5
attem pt to elicit inform ation by being nonjudgm ental and Ra tiona le: When the client is experiencing withdrawal from
direct. Option 1 is incorrect because it is judgm ental and off- alcohol, the priority for care is to prevent the client from harm -
focus, and reflects the nurse’s bias. Option 3 is incorrect ing self or others. The nurse would m onitor the vital signs
because it is judgm ental, insensitive, and aggressive, which is closely and report abnorm al findings. The nurse would provide
nontherapeutic. Option 4 is incorrect because it indicates pas- a low-stim ulation environm ent to m aintain the client in as
sivity on the nurse’s part and uses rationalization to avoid the calm a state as possible. The nurse would reorient the client
therapeutic nursing intervention. to reality frequently and would address hallucinations thera-
Test-Ta king Stra tegy: Focus on the subject, providing appro- peutically. Adequate nutritional and fluid intake need to be
priate nursing care. Use of th erapeutic com m un ication tech - m aintained.
n iques will assist in directing you to the correct option. Test-Ta king Stra tegy: Note the strategic words, most appropri-
Review: Assessm ent of a client who is dependent on drugs ate. Thinking about the needs of the client in alcohol with-
Level of Cognitive Ability: Applying drawal and recalling the characteristics associated with
Client Needs: Psychosocial Integrity alcohol withdrawal will assist in answering correctly. Also,
Integra ted Process: Nursing Process—Assessm ent use th erapeutic com m un ication tech n iques to assist in
Content Area : Mental Health selecting the correct interventions.