In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?

Alcohol can interact with medications and can make some diseases worse

This information is necessary to determine the patient’s reliability

This information is not necessary unless a drinking problem is obvious

The nurse needs to be able to teach all patients to avoid any alcohol consumption

Answer and Explanation

The Correct Answer is A

Choice A reason: Alcohol can interact with medications, altering their metabolism via liver enzymes (e.g., CYP450), and exacerbate conditions like liver disease or hypertension. This information is critical for safe treatment planning, making it the primary reason for inquiry.

Choice B reason: Assessing patient reliability is not the purpose of asking about alcohol use. This question focuses on clinical implications, not trustworthiness, as alcohol’s effects on health and medications are the priority, making this an incorrect rationale.

Choice C reason: Alcohol use is relevant even without an obvious drinking problem, as even moderate consumption can affect medication efficacy or disease progression. Dismissing this question unless a problem is evident overlooks potential risks, making this incorrect.

Choice D reason: Teaching all patients to avoid alcohol is not universally necessary, as moderate use may be safe for some. The inquiry aims to identify specific risks, like drug interactions, not to enforce blanket abstinence, making this an incorrect reason.

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Correct Answer is B

Explanation

Choice A reason: Offering a finger may elicit sucking, not rooting, which involves head-turning toward a stimulus. Stroking the cheek triggers the rooting reflex, so this is incorrect for testing the specific reflex.

Choice B reason: Stroking the infant’s cheek near the mouth elicits the rooting reflex, causing the newborn to turn toward the stimulus, seeking to nurse. This is the correct technique for testing this reflex.

Choice C reason: Jarring the crib tests the Moro reflex, not rooting, which is unrelated to startle responses. Cheek stroking is specific to rooting, so this incorrect for the reflex being assessed.

Choice D reason: Stroking the foot edge tests the Babinski reflex, not rooting, which involves oral seeking. The cheek is the correct area to stimulate, so this is incorrect for the rooting reflex.

A. Use the Brief Pain Inventory to assess the patient’s pain B. Observe the patient’s body language for pacing and agitation C. Note whether the patient is calling out, groaning, or crying D. Assess the patient’s breathing independent of vocalization E. Have the patient rate pain on a 1-to-10 scale

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: The Brief Pain Inventory relies on verbal or cognitive input, which is unreliable in advanced dementia due to impaired communication and cognition. Patients may not articulate pain, making this tool ineffective for assessing pain in this population.

Choice B reason: Observing body language, like pacing or agitation, is a valid pain indicator in advanced dementia. These nonverbal behaviors reflect discomfort processed by intact pain pathways, despite cognitive decline, making this a reliable assessment method.

Choice C reason: Noting vocalizations like groaning or crying is effective, as these are instinctive responses to pain, even in advanced dementia. These behaviors bypass cognitive deficits, reflecting pain perception in the brain’s nociceptive pathways, making this a correct choice.

Choice D reason: Assessing breathing changes, like rapid or irregular patterns, is a reliable nonverbal pain indicator in dementia. Pain can stimulate the autonomic nervous system, altering respiration independently of vocalization, making this a valid assessment technique.

Choice E reason: A 1-to-10 pain scale requires cognitive ability to quantify and communicate pain, which is impaired in advanced dementia. This method is unreliable, as patients cannot reliably report, making it an incorrect choice for this population.

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In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An instructor asks a nursing student to test a newborn’s rooting reflex. Which technique would be correct?

Correct Answer is B

Explanation

Which of the following could the nurse use to assess indicators of pain experienced by a patient with advanced dementia? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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