Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

Chapter 07: Substance Use and Health Assessment

Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition

MULTIPLE CHOICE

1. A woman has come to the clinic to seek help for a substance abuse problem. She admits to
using cocaine just before arriving. Which of these assessment findings would the nurse expect
to find when examining this woman?
a. Dilated pupils, pacing, and psychomotor agitation
b. Dilated pupils, unsteady gait, and aggressiveness
c. Pupil constriction, lethargy, apathy, and dysphoria
d. Constricted pupils, euphoria, and decreased temperature
ANS: A
A cocaine user’s appearance includes pupillary dilation, tachycardia or bradycardia, elevated
or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The person’s
behaviour includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation,
impaired social or occupational functioning, fighting, grandiosity, and visual or tactile
hallucinations.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

2. A patient has been admitted to the hospital after a weekend of binge drinking. What are some
signs the nurse will observe indicating withdrawal from alcohol?
a. Bradycardia and vasodilation
b. Euphoria and elation NURSINGTB.COM
c. Anxiety, agitation, and diaphoresis
d. Depression and hunger
ANS: C
Signs and symptoms of withdrawal can include insomnia; autonomic symptoms, such as
sweating or racing heart; increased hand tremors (known as “the shakes”); nausea and/or
vomiting; psychomotor agitation (feeling physically restless, inability to stop moving);
anxiety; seizures; rarely, hallucinations, or perceptual disturbances of the auditory, tactile, or
visual type.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

3. As the nurse is preparing the patient for surgery, he states that he usually has three glasses of
wine a night to relax and help him sleep. What else will the nurse need to assess the patient
postoperatively in addition to the regular postoperative assessments?
a. Mental status
b. Withdrawal symptoms
c. No addictions
d. Depression
ANS: B

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

When patients are admitted to the hospital, their usual patterns of substance use are
interrupted. If documentation of the history includes substance use you should be alert to the
need to assess for and manage withdrawal. Alcohol withdrawal is most likely to be
encountered, and all care providers should have a basic knowledge of the signs and symptoms
of withdrawal.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

4. While working with a group of university students, the nurse undertakes a harm reduction
approach to alcohol consumption by introducing:
a. Narcotics Anonymous
b. Canada’s Low-risk Alcohol Drinking Guidelines
c. Alcoholics Anonymous
d. Tobacco Cessation
ANS: B
Harm reduction aims to reduce the harms of substance use. Canada’s Low-risk Alcohol
Drinking Guidelines were developed to help Canadians moderate alcohol consumption and
decrease alcohol-related harm, such as drinking and driving, and provide tips for safe drinking
and not drinking while pregnant. Alcoholics Anonymous takes on an approach of abstinence.
An abstinence approach aims to reduce the use of alcohol entirely.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential

5. While admitting a patient with liver failure resulting from consumption of harmful amounts of
NURassessment
alcohol, the nurse should include SINGTB.C of: OM
a. Pregnancy
b. Cultural practices
c. Mental health
d. Spiritual beliefs
ANS: C
Mental health and substance use are consistently linked. Nurses must understand that histories
of trauma are common among people who have problems with substance use and among
people with mental health problems, such as post-traumatic stress disorder (PTSD) and
depression.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential

6. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric
visit. She asks the nurse, “How many drinks a day is safe for my baby?” The nurse’s best
response is:
a. “You should limit your drinking to once or twice a week.”
b. “It’s okay to have up to two glasses of wine a day.”
c. “As long as you avoid getting drunk, you should be safe.”
d. “No amount of alcohol has been determined to be safe during pregnancy.”
ANS: D

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

No amount of alcohol has been determined to be safe for pregnant women. The potential
adverse effects of alcohol use on the fetus are well known; women who are pregnant should
be screened for alcohol use, and abstinence should be recommended.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

7. The nurse is arranging a health promotion information session for the community’s older
adults. What is a common concern for the older adult population regarding substance use
should the nurse include?
a. Binge drinking to conform
b. Risks of taking many different medications
c. Facing judgment for using marijuana
d. Medicating for behaviour problems
ANS: B
Many older adults take multiple medications and can be overmedicated with prescription
medications as well as self-medicating with over-the-counter medications.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential

8. During the first meeting with the patient, the nurse takes a respectful, least invasive approach
to assessing substance use by asking:
a. “How much do you drink?”
b. “What types of drugs do you use?”
c. “What drugs are you injecting?”
d. “Do you drink alcohol atN URSINGTB.COM
all?”
ANS: D
To take a respectful, minimally invasive approach, avoid conveying assumptions, and make
your questions specific. For example, with regard to alcohol, first ask “Do you drink alcohol?”
Do not ask questions that assume they do drink or use illicit substances.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential

9. Having affirmed alcohol use, the nurse is asking an adolescent about illicit substance use. The
adolescent answers, “Yes, I’ve tried cocaine at parties with my friends.” What is the next
question the nurse should ask?
a. “Who are these friends?”
b. “Do your parents know about this?”
c. “How much did you use?”
d. “Is this a regular habit?”
ANS: C
If a patient admits to the use of illicit substances, then the nurse should ask progressively more
detailed questions about what substances were used, amount of substance used, how often, by
what route, for how long these substances were used, and the last time used. The other
questions may be considered accusatory and are not conducive to gathering information.

DIF: Cognitive Level: Applying (Application)

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

MSC: Client Needs: Health Promotion and Maintenance

10. The nurse has completed an assessment on a patient who came to the clinic for a leg injury.
As a result of the assessment, the patient states desire to quit drinking. Which action by the
nurse is most appropriate at this time?
a. Record the results of the assessment, and notify the physician on call.
b. State, “I can help you and will arrange for someone from the addictions team to
come speak with you about quitting drinking.”
c. State, “It appears that you may have a drinking problem. Here is the telephone
number of our local Alcoholics Anonymous chapter.”
d. Give the patient information about a local rehabilitation clinic.
ANS: B
With identification that a patient would like to stop drinking, the nurse should follow up
appropriately and offer assistance respectfully and have resources to offer patients
(educational, clinical, and community resources). Simply giving out a telephone number or
referral to agencies may not be enough.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

11. A patient is brought to the emergency department. He is restless, has dilated pupils, is
sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His
girlfriend thinks he has influenza, but she became concerned when his temperature went up to
39.4°C. She admits that he has been a heavy drug user, but he has been trying to stop on his
own. The nurse suspects that the patient is experiencing withdrawal symptoms from which
substance?
a. Alcohol NURSINGTB.COM
b. Heroin
c. Crack cocaine
d. Sedatives
ANS: B
Withdrawal symptoms of opiates, such as heroin, are similar to the clinical picture of
influenza and include symptoms such as dysphoric mood; nausea or vomiting; muscle aches;
lacrimation or rhinorrhea; pupillary dilation, piloerection, or sweating; diarrhea; yawning;
fever; insomnia. (See Table 7-1.)

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

12. The nurse is reviewing aspects of substance use in preparation for a seminar. Which of these
statements illustrates the concept of tolerance to an illicit substance? The person:
a. Has a physiological dependence on a substance.
b. Requires an increased amount of the substance to produce the same effect.
c. Requires daily use of the substance to function and is unable to stop using it.
d. Experiences a syndrome of physiologic symptoms if the substance is not used.
ANS: B

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

The concept of tolerance to a substance indicates that the person requires an increased amount
of the substance to produce the same effect. Harmful substance use occurs when the person
needs to use the substance daily to function, and the person is unable to stop using it.
Dependence is an actual physiological dependence on the substance. Withdrawal occurs when
cessation of the substance produces a syndrome of physiological symptoms.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

13. The nurse is caring for a mother after the delivery of her infant. The mother had reported
using an antidepressant through her pregnancy and is worried about her baby. The nurse
should reassure the mother and:
a. Inform her that she should not have been taking antidepressants while pregnant.
b. Promote skin-to-skin contact and breastfeeding to support mother and baby.
c. Inform her that the baby will need medication to treat the withdrawal.
d. Remove the baby from her care.
ANS: B
To help eliminate barriers to care, the nurse can be welcoming to the patient and reassure her
that her well-being is the primary goal. By caring for the mother, you are caring for the
fetus/infant. Some infants prenatally exposed to substances, such as opiates, antidepressants,
and certain prescription medications, may exhibit symptoms of withdrawal in the first hours to
days of life; however, when carefully monitored and managed with rooming-in with the
mother, skin-to-skin contact, and breastfeeding, most such infants do not require medical
treatment for withdrawal.

DIF: Cognitive Level: Understanding (Comprehension)

NUIntegrity:
MSC: Client Needs: Physiologic RSINGPhysiologic
TB.COMAdaptation
14. The nurse is admitting a patient with a history of cocaine use. The nurse will document:
a. Patient is an addict and lives on the street.
b. Patient is seeking drugs and wants any drug he can have.
c. Patient is a cocaine addict.
d. Patient states injecting cocaine daily over the past week.
ANS: D
Documentation about the use of substances needs to be objective and nonjudgemental.
Documentation should avoid the use of stigmatizing labels. Documentation should not make
assumptions about the patient, such as drug seeking and living on the street.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. A patient with a known history of heavy alcohol use has been admitted to the intensive care
unit after he was found unconscious outside a bar. The nurse closely monitors him for
symptoms of withdrawal. Which of these symptoms may occur during this time? (Select all
that apply.
a. Bradycardia

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

b. Increased hand tremors

c. Nausea
d. Somnolence
e. Sweating
ANS: B, C, E
Symptoms of uncomplicated alcohol withdrawal start shortly after the cessation of drinking,
peak at the second day, and improve by the fourth or fifth day. Signs and symptoms of
withdrawal can include insomnia; autonomic symptoms, such as sweating or racing heart;
increased hand tremors (known as “the shakes”); nausea and/or vomiting; psychomotor
agitation (feeling physically restless, inability to stop moving); anxiety; seizures; rarely,
hallucinations, or perceptual disturbances of the auditory, tactile, or visual type. (See Table
7-1.)

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

2. A patient visits the clinic to ask about smoking cessation. He has smoked heavily for 30 years
and wants to stop “cold turkey.” He asks the nurse, “What symptoms can I expect if I do
this?” Which of these symptoms should the nurse share with the patient as possible symptoms
of nicotine withdrawal? (Select all that apply.)
a. Headaches
b. Hunger
c. Sleepiness
d. Restlessness
e. Nervousness
f. Sweating
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ANS: A, B, D, E
Symptoms of nicotine withdrawal include vasodilation, headaches, anger, irritability,
frustration, anxiety, nervousness, awakening at night, difficulty concentrating, depression,
hunger, impatience, and the desire to smoke. (See Table 7-1.)

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

3. To advocate for a harm reduction approach to substance use the nurse suggests:
a. Safe injection sites
b. Abstinence
c. Providing clean needles
d. Developing safe housing
e. Public access to naloxone kits
f. Complete cessation of substance use
ANS: A, C, D, E
Harm reduction strategies related to substance use include providing access to safe substances
(e.g., providing heroin that is not cut with more harmful substances, e.g., fentanyl), safe
supplies (e.g., crack pipes that will not cut people’s lips or clean needles), safe places to use
substances (e.g., safe injection sites) and overdose care, such as the public distribution of
naloxone (Narcan) kits. Harm reduction also includes more “upstream” approaches, such as
safe housing, income supports, and pain-management services.

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 Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance: Reduction of Risk Potential

4. After history taking and physical assessment of a patient with a known history of illicit
substance use, what information will the nurse chart? (Select all that apply.)
a. The patient is a known drug user.
b. The patient states using cocaine daily via injection and snorting.
c. The patient is using cocaine, and the police have been informed.
d. The patient states using safe injections sites for cocaine injection.
e. The patient is a druggie and addicted to cocaine.
ANS: B, D
Objective documentation is factual and nonjudgemental. The use of stigmatizing labels and
language should be avoided. There is no legal requirement to report illicit substance use and
would breach patient confidentiality. The term addiction has a very specific meaning, and it
serves as a diagnosis that nurses are not qualified to make. Labelling someone an addict or has
an addiction unless specifically diagnosed, is stigmatizing.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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