The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query.
What interpretation should the nurse provide to the patient?
One positive response indicates the patient should seek help with alcohol addiction.
All responses to the CAGE Questionnaire must be positive to suggest alcohol dependence.
The CAGE Questionnaire is a tool used to identify general substance abuse.
At least two positive responses are strongly suggestive of alcohol dependence.
The Correct Answer is D
Choice A rationale
While any positive response on the CAGE questionnaire could be a cause for concern and warrant further investigation, one positive response does not definitively indicate that the patient should seek help with alcohol addiction. The CAGE questionnaire is a screening tool used to identify potential problems with alcohol, but it is not diagnostic. A healthcare provider would need to conduct a more thorough assessment to diagnose alcohol addiction.
Choice B rationale
It is not necessary for all responses to the CAGE questionnaire to be positive in order to suggest alcohol dependence. The CAGE questionnaire is a screening tool, and while a greater number of positive responses increases the likelihood of alcohol dependence, it is not a requirement for all responses to be positive. A score of two or more is considered clinically significant.
Choice C rationale
The CAGE questionnaire is indeed a tool used to identify potential problems with alcohol, but it is not used to identify general substance abuse. The CAGE questionnaire specifically asks about feelings related to alcohol use. There are other screening tools available that are designed to identify issues with other substances.
Choice D rationale
This is the correct answer. The CAGE questionnaire is a validated screening tool that is widely used in clinical settings to detect alcoholism. It is considered positive, and suggestive of alcohol dependence, if two or more questions are answered affirmatively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering oxygen via a face mask is the first intervention the nurse should do. This is because the decrease in fetal heart rate after the last four contractions indicates possible fetal distress, which can be caused by insufficient oxygen. Administering oxygen to the mother can increase the amount of oxygen available to the fetus, potentially alleviating the distress.
Choice B rationale
Applying an internal fetal heart monitor can provide more accurate and continuous data about the fetal heart rate and contractions. However, this is usually not the first intervention because it is invasive and can only be done if the cervix is sufficiently dilated and the membranes have ruptured.
Choice C rationale
Using a vibroacoustic stimulator is a method used to wake a sleeping baby in the womb during a non-stress test. It is not typically used in response to signs of fetal distress during labor.
Choice D rationale
Notifying the healthcare provider is important when there are signs of fetal distress. However, the nurse has interventions, such as administering oxygen, that they can and should do immediately while the healthcare provider is being notified.
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
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