The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

By using a screening tool such as the CAGE questionnaire

By asking directly if the client has ever had a problem with alcohol

By holistically assessing the client using the CINA scale

By referring the client for physician evaluation

Answer and Explanation

The Correct Answer is A

A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.

B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.

C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.

D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.

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Correct Answer is D

Explanation

A. Having an advanced degree in engineering:

While pursuing an advanced degree can be challenging, it is not inherently a source of psychological distress. It may represent a personal and professional accomplishment.

B. Attending a community center daily:

Attending a community center daily is a regular activity and may not necessarily be a source of psychological distress. It could be a positive and fulfilling aspect of one's routine.

C. Belonging to the middle-class socioeconomic group:

Belonging to the middle-class socioeconomic group is not inherently a source of psychological distress. Socioeconomic status alone does not determine psychological well-being, and being in the middle class can provide stability and resources.

D. Being the only person of their ethnicity in a school setting:

This qualifies as a source of psychological distress. Being the only person of a particular ethnicity in a school setting may lead to feelings of isolation, cultural dissonance, and a sense of being different. Such situations can contribute to psychological distress and impact mental well-being.

A. "The voices talk only at night when I'm trying to sleep." B. The voices say everyone is trying to kill me. C. I hear angels playing harps

Correct Answer is B

Explanation

A. "The voices talk only at night when I'm trying to sleep."

This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.

B. "The voices say everyone is trying to kill me."

This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.

C. "I hear angels playing harps."

This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.

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The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?

Correct Answer is D

Explanation

Which hallucination necessitates the nurse to implement safety measures? The patient says.

Correct Answer is B

Explanation

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

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