The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
Cancer screening results, anger, gastritis, daily alcohol intake.
Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
Efforts to cut down, annoyance with questions, guilt, and drinking as an "Eye-opener."
Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
The Correct Answer is C
Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.
Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."
Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.
Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Clonazepam is not typically associated with a significant risk of causing urinary retention or frequent bathroom needs. There's no immediate need for bathroom assistance related to clonazepam use.
Choice B rationale:
Clonazepam is a medication that affects the central nervous system and can influence mental status. Regular assessment helps monitor for any changes or adverse effects.
Choice C rationale:
Clonazepam is administered orally, and it's important to ensure the client's oral health and comfort, especially since dry mouth can be a side effect.
Choice D rationale:
Clonazepam can cause drowsiness and potential changes in blood pressure, which could lead to orthostatic hypotension. Screening for this condition helps ensure the client's safety when changing positions.
Choice E rationale:
Clonazepam does not typically affect calcium levels. Monitoring calcium levels is not a standard nursing intervention when starting clonazepam.
Choice F rationale:
Clonazepam is not an opioid, and it does not require having an opioid agonist at the bedside. This intervention is not relevant to clonazepam use.
Correct Answer is D
Explanation
A. Any history of heart disease: While a history of heart disease is important for general health, it is not the most critical factor prior to initiating sertraline. The nurse should still assess for cardiovascular conditions, but this is not the most pressing concern.
B. Familial history of mental illness: While a familial history of mental illness can inform treatment decisions, it is not the most immediate or critical piece of information before starting sertraline.
C. Current weight: Weight is generally not the primary consideration before starting sertraline. However, weight changes can occur during treatment, but this is more of a concern during the ongoing management of the medication.
D. Medication history: Sertraline, as a selective serotonin reuptake inhibitor (SSRI), can interact with other medications, especially those affecting serotonin levels (e.g., other antidepressants, MAO inhibitors, etc.). It is crucial to assess the client’s current medication history to prevent harmful drug interactions, such as serotonin syndrome. This is the most important information to gather before initiating treatment.
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