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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.
B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.
C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.
D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.
Correct Answer is A
Explanation
A. WBC count 3,300/mm³.
Clozapine, an atypical antipsychotic medication, is associated with a risk of agranulocytosis, which is a severe reduction in white blood cell (WBC) count. A WBC count of 3,300/mm³ is significantly below the normal range, and it indicates a contraindication to the use of clozapine.
B. Asthma:
Asthma is not a contraindication to clozapine. However, it is important to monitor respiratory function as antipsychotic medications can have side effects related to respiratory function.
C. Hypertension:
Hypertension alone is not a contraindication to clozapine. Clozapine can, however, be associated with some cardiovascular side effects, so blood pressure should be monitored regularly.
D. Fasting blood glucose 120 mg/dL:
An elevated fasting blood glucose level is not a contraindication to clozapine. However, it is important to monitor metabolic parameters as antipsychotic medications, including clozapine, can be associated with metabolic side effects.
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