Substance use, withdrawal, abuse and violence

44 NCLEX-RN practice questions on Substance use, withdrawal, abuse and violence, part of Psychosocial Integrity. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium · Select all that apply

   A client who is experiencing intimate partner violence is not ready to leave the relationship. Which items should the nurse include when helping the client make a safety plan?

   1. AKeep a packed bag with clothes and medicines hidden or at a friend's home
   2. BPlan the safest route out of the home and a place to go
   3. CAgree on a code word that tells a friend to call the police
   4. DKeep copies of identity papers, bank cards and spare keys in a safe place
   5. ESave the domestic violence hotline number where the partner will not find it
   6. FTell the partner about the plan so that he can calm down beforehand

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   Answer: A, B, C, D, E

   Generate solutions: a client who stays still needs a safety plan: a hidden bag, copies of documents and keys, a code word, hotline numbers and an escape route. The decision to leave belongs to the client, and the period of leaving is when violence is most likely to escalate, so the plan is kept secret from the partner.

   • F: Leaving is the most dangerous time; warning the abuser raises the risk of serious harm.

2. Question 2 · Medium · Matrix

   A home health nurse visits an 84-year-old client who lives with a grandson. For each finding, indicate the type of mistreatment it most suggests.

   For each row, choose: Physical abuse / Neglect / Financial exploitation

   1. Bruises on both upper arms in the shape of fingers
   2. Utility shut-off notices while the grandson uses the client's bank card
   3. Client recently signed over the house title and says the grandson told her to
   4. Prescribed medicines not refilled for a month
   5. Stage 3 pressure injury and soiled bedding

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   Answer:

   • Bruises on both upper arms in the shape of fingers: Physical abuse
   • Utility shut-off notices while the grandson uses the client's bank card: Financial exploitation
   • Client recently signed over the house title and says the grandson told her to: Financial exploitation
   • Prescribed medicines not refilled for a month: Neglect
   • Stage 3 pressure injury and soiled bedding: Neglect

   Analyse cues: elder mistreatment includes physical, sexual and emotional abuse, neglect and financial exploitation, and often several types occur together. The nurse documents the findings objectively, assesses the client's safety and reports the suspicion according to state law and agency policy, usually to adult protective services.

   • Bruises on both upper arms in the shape of fingers: Grip-shaped bruises suggest forceful grabbing.
   • Utility shut-off notices while the grandson uses the client's bank card: Misuse of the client's money suggests financial exploitation.
   • Client recently signed over the house title and says the grandson told her to: Pressured transfer of property is financial exploitation.
   • Prescribed medicines not refilled for a month: Failure to provide needed care is neglect.
   • Stage 3 pressure injury and soiled bedding: Unmet basic care points to neglect by the caregiver.

3. Question 3 · Medium · Select all that apply

   A client with long-term heavy alcohol use and poor nutrition is admitted with a fall. Which findings should the nurse recognise as possible signs of Wernicke encephalopathy?

   1. AYellow sclerae
   2. BUnsteady, wide-based gait
   3. CNew confusion and inattention
   4. DPinpoint pupils
   5. ENystagmus or weakness of eye movements

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   Answer: B, C, E

   Analyse cues: Wernicke encephalopathy, caused by thiamine deficiency, shows confusion, ataxia and eye-movement signs, though few clients have all three. It is an emergency treated with parenteral thiamine, given before glucose-containing fluids, to prevent permanent memory loss (Korsakoff syndrome).

   • A: Jaundice points to liver disease, not thiamine deficiency.
   • D: Miosis suggests opioid effect.

4. Question 4 · Medium · Matrix

   A client is placed in physical restraints after assaulting a staff member. For each action, indicate whether it is appropriate or inappropriate nursing care.

   For each row, choose: Appropriate / Inappropriate

   1. Ensure the client is seen face to face by a qualified provider or trained RN within 1 hour
   2. Fasten the straps to the movable bed frame
   3. Tie the straps to the side rails
   4. Remove the restraints as soon as the client meets release criteria
   5. Offer fluids and toileting at regular intervals
   6. Obtain an as-needed (PRN) restraint order for future episodes

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   Answer:

   • Ensure the client is seen face to face by a qualified provider or trained RN within 1 hour: Appropriate
   • Fasten the straps to the movable bed frame: Appropriate
   • Tie the straps to the side rails: Inappropriate
   • Remove the restraints as soon as the client meets release criteria: Appropriate
   • Offer fluids and toileting at regular intervals: Appropriate
   • Obtain an as-needed (PRN) restraint order for future episodes: Inappropriate

   Take action: restraint for violent behavior needs a time-limited order (never PRN), a face-to-face evaluation within 1 hour, continuous or frequent monitoring of circulation, skin and breathing, regular fluids and toileting, attachment to the bed frame and release as soon as the client is safe.

   • Ensure the client is seen face to face by a qualified provider or trained RN within 1 hour: Federal rules require a face-to-face evaluation within 1 hour of restraint for violent behavior.
   • Fasten the straps to the movable bed frame: The frame moves with the bed, so the straps do not tighten when the bed is raised.
   • Tie the straps to the side rails: Lowering a rail can injure the client's limb.
   • Remove the restraints as soon as the client meets release criteria: Restraint ends at the earliest possible time.
   • Offer fluids and toileting at regular intervals: Basic needs are met during restraint.
   • Obtain an as-needed (PRN) restraint order for future episodes: Restraint orders may never be written as PRN.

5. Question 5 · Easy · Matrix

   For each finding, indicate whether it is more typical of opioid intoxication or of opioid withdrawal.

   For each row, choose: Opioid intoxication / Opioid withdrawal

   1. Frequent yawning and a runny nose
   2. Slow, shallow respirations
   3. Dilated pupils and diarrhea
   4. Drowsiness and slurred speech
   5. Constricted, pinpoint pupils
   6. Gooseflesh and muscle aches

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   Answer:

   • Frequent yawning and a runny nose: Opioid withdrawal
   • Slow, shallow respirations: Opioid intoxication
   • Dilated pupils and diarrhea: Opioid withdrawal
   • Drowsiness and slurred speech: Opioid intoxication
   • Constricted, pinpoint pupils: Opioid intoxication
   • Gooseflesh and muscle aches: Opioid withdrawal

   Analyse cues: withdrawal looks like the opposite of the drug's effects. Intoxication brings miosis, sedation and slow breathing; withdrawal brings mydriasis, yawning, rhinorrhea, piloerection, aches and diarrhea, which are distressing but rarely life-threatening in adults.

   • Frequent yawning and a runny nose: Yawning and rhinorrhea are early withdrawal signs.
   • Slow, shallow respirations: Respiratory depression is the danger of opioid excess.
   • Dilated pupils and diarrhea: Withdrawal produces the opposite of opioid effects: mydriasis and increased bowel activity.
   • Drowsiness and slurred speech: Sedation is a sign of opioid excess.
   • Constricted, pinpoint pupils: Opioids stimulate pupil constriction.
   • Gooseflesh and muscle aches: Piloerection and myalgia appear as the drug leaves the body.

6. Question 6 · Hard · Select all that apply

   A client in the emergency department has a swollen eye and bruised ribs. She says her husband hit her with a frying pan last night. Her husband is in the waiting room. Which actions should the nurse take?

   1. AKeep the interview private, with the husband outside the room
   2. BRecord the client's own words in quotation marks
   3. CDelay treatment of the injuries until police arrive
   4. DWrite in the record that the husband is an abuser
   5. EMark the injuries on a body map and photograph them with her consent
   6. FAsk the husband to confirm how the injuries happened

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7. Question 7 · Medium · Select all that apply

   A client is receiving lofexidine to relieve symptoms of opioid withdrawal. Which assessments should the nurse make before each dose?

   1. ABlood pressure lying and standing
   2. BPeak expiratory flow
   3. CDeep tendon reflexes
   4. DFingerstick blood glucose
   5. EApical heart rate

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8. Question 8 · Hard · Matrix

   A client with a fentanyl overdose woke after two doses of IV naloxone. He is now sweating, vomiting and shouting that the nurse ruined his high. RR 16, SpO2 95% on room air. For each action, indicate whether it is indicated or contraindicated now.

   For each row, choose: Indicated / Contraindicated

   1. Keep continuous pulse oximetry and frequent respiratory checks
   2. Give a third naloxone dose to fully reverse the opioid
   3. Offer referral to opioid treatment and a naloxone kit
   4. Turn the client onto his side while he is vomiting
   5. Apply four-point restraints because he is shouting

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9. Question 9 · Medium · Select all that apply

   A client on an inpatient psychiatric unit is pacing, swearing and saying he was cheated out of his phone time. Which de-escalation actions should the nurse use?

   1. ATurn sideways and away from him to show trust
   2. BPlace a hand on his shoulder to reassure him
   3. COffer him a choice of a quiet room or a prescribed as-needed medicine
   4. DTell him that he will be restrained if he does not calm down
   5. ESpeak in a calm, low voice using short sentences
   6. FAcknowledge his frustration about the phone

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10. Question 10 · Hard · Select all that apply

    The nurse reviews four new admissions to an acute psychiatric unit to decide who needs closer observation for violence. Which client factors increase the risk of violence toward others?

    1. ACurrent intoxication with alcohol
    2. BA history of assaulting staff during a previous admission
    3. CA request to speak with the unit's patient advocate
    4. DAdmission on an involuntary hold against the client's wishes
    5. ETaking a prescribed selective serotonin reuptake inhibitor
    6. FCommand hallucinations telling the client to hurt someone

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11. Question 11 · Hard · Select all that apply

    A client admitted for a leg fracture had his last alcoholic drink 60 hours ago. He is now sweating heavily and says snakes are coming out of the wall. Which findings require immediate follow-up?

    1. AVisual hallucinations of snakes
    2. BHeart rate 128/min
    3. CBlood pressure 176/104 mm Hg
    4. DAsks for something to eat
    5. ETemperature 101.8 °F (38.8 °C)
    6. FCannot say where he is or what day it is

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12. Question 12 · Easy · Select all that apply

    The nurse teaches the partner of a client with opioid use disorder how to use a nasal naloxone spray at home. Which instructions should the nurse include?

    1. ACall 911 as soon as an overdose is suspected
    2. BWait to see whether the person wakes before calling for help
    3. CUse the spray only if the person has no pulse
    4. DStay with the person and turn them onto their side
    5. ESpray one dose into one nostril
    6. FGive a second dose from a new device after 2 to 3 minutes if there is no response

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13. Question 13 · Medium · Select all that apply

    The nurse is scoring a client on the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar). Which items does the nurse rate as part of this scale?

    1. AOrientation and clouding of the sensorium
    2. BTremor of the outstretched arms
    3. CAnxiety
    4. DTactile disturbances such as itching or crawling skin
    5. EBlood pressure and heart rate
    6. FSize of the pupils

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14. Question 14 · Hard · Matrix

    A client at 20 weeks' gestation with opioid use disorder has just started methadone. For each statement she makes, indicate whether it shows understanding or needs more teaching.

    For each row, choose: Shows understanding / Needs more teaching

    1. Methadone will help keep both me and the baby out of withdrawal.
    2. Naloxone can never be used while I am pregnant.
    3. I can usually breastfeed while I stay on methadone.
    4. I should stop all opioids on my own right away to protect the baby.
    5. Missing my clinic doses will not matter much.
    6. The nurses will watch the baby for withdrawal signs after birth.

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15. Question 15 · Hard · Select all that apply

    A client on a psychiatric unit punched a nurse in the face before being calmed. The nurse has a swollen lip and feels shaky but wants to finish the shift. Which actions are appropriate after the assault?

    1. AGo back alone to the client to repair the relationship right away
    2. BReport the assault to the charge nurse at once
    3. CComplete an incident report according to agency policy
    4. DGet a medical evaluation of the injury
    5. EAccept the assault as a normal part of psychiatric nursing
    6. FNote in the client's record that an incident report was filed

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16. Question 16 · Medium · Matrix

    A nurse in a pediatric urgent care clinic assesses several children. For each finding, indicate whether it suggests possible abuse or is typical of an accidental injury.

    For each row, choose: Suggests possible abuse / Typical accidental injury

    1. Bruises over the shins of an active 4-year-old
    2. Bruising on the buttocks and earlobes of a toddler
    3. Burns on both feet with a sharp line like a sock
    4. Round burns about 8 mm across on the palms
    5. Scraped palms and chin after a fall from a scooter

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17. Question 17 · Hard

    Before discharge, a client with opioid use disorder receives the first monthly extended-release naltrexone injection and teaching about overdose risk. Which client statement indicates a need for further teaching?

    1. AI need to tell any surgeon or dentist that I am getting naltrexone
    2. BI must stay off all opioids for 7 to 10 days before the first injection
    3. CMy tolerance will be low if I stop the shots, so an old dose could kill me
    4. DIf cravings get bad, I can use a little heroin and the shot will keep me safe

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18. Question 18 · Hard

    A term newborn, 48 hours old, was exposed to methadone in pregnancy. Nurses' notes, 0900: tremors when disturbed, high-pitched cry, frequent sneezing, loose stool. Fed 25 mL of formula well at 0800, slept 70 minutes after the feed, and calmed within 8 minutes when held skin to skin by the mother. As-needed oral morphine is prescribed for withdrawal that nonpharmacologic care does not control. What should the nurse do?

    1. ASchedule hourly handling to check the withdrawal signs
    2. BMove the infant to the nursery for closer watching
    3. CContinue swaddling, rooming-in and a quiet, dim room
    4. DGive the as-needed morphine dose now

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19. Question 19 · Medium

    Which statement by the nurse is the best way to screen a female client for intimate partner violence?

    1. ABecause violence is common, I ask all my clients: has anyone hurt you or made you afraid?
    2. BYour partner seems very caring, so I assume you feel safe at home, is that right?
    3. CWhy did you not tell anyone sooner that your partner was hurting you?
    4. DYou do not seem to be the type of person who would be abused, but I have to ask.

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20. Question 20 · Medium

    A client who has used heroin daily stopped 18 hours ago. Which finding should the nurse recognise as part of opioid withdrawal?

    1. APinpoint pupils and slow, slurred speech
    2. BVisual hallucinations of insects
    3. CBradycardia and a dry, warm skin
    4. DYawning, tearing and dilated pupils

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21. Question 21 · Hard

    A client is on day 3 after a hip repair. Nurses' notes at 0300: restless, pulling at the IV line, says insects are crawling on the wall; does not know the date. Vital signs: T 100.6 °F (38.1 °C), HR 124, BP 168/98, RR 22. Skin moist, hands tremulous. The wound is clean and dry, and the WBC count is normal. The spouse reports the client drinks a fifth of whiskey daily. Which condition should the nurse suspect first?

    1. APost-operative wound infection
    2. BAlcohol withdrawal delirium
    3. COpioid analgesic toxicity
    4. DWorsening uncontrolled pain

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22. Question 22 · Medium

    Before giving the first dose of buprenorphine-naloxone to a client with opioid use disorder, the nurse should confirm that the client:

    1. AHas eaten a full meal in the past hour
    2. BShows objective signs of moderate withdrawal
    3. CHas a urine drug screen negative for opioids
    4. DUsed an opioid within the last two hours

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23. Question 23 · Medium

    A visitor shouts at the nurses' station that he will "come back and make everyone pay" and then leaves. What should the nurse do first?

    1. AIgnore the remark because the visitor has already left the unit
    2. BNotify security and follow the facility's workplace-violence policy
    3. CPost the visitor's photograph on the staff group chat
    4. DWait to report the threat until the end of the shift

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24. Question 24 · Hard

    A client in alcohol withdrawal received lorazepam 2 mg twice in the last 3 hours. At reassessment: CIWA-Ar 6, arousable only to firm touch, RR 10, SpO2 90% on room air, HR 84. What is the nurse's best action?

    1. AGive the next lorazepam dose to keep symptoms controlled
    2. BWithhold lorazepam, stimulate the client and support breathing
    3. CAsk assistive personnel to sit with the client and watch
    4. DRecord the result and recheck the client in 4 hours

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25. Question 25 · Easy

    The set of findings most typical of acute opioid toxicity is:

    1. APinpoint pupils, slow shallow breathing and stupor
    2. BHyperthermia, chest pain, agitation and dilated pupils
    3. CDilated pupils, yawning, runny nose and gooseflesh
    4. DTremor, sweating, hypertension and visual hallucinations

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