When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Involve client in daily exercise program.

Ask the client to describe her depression.

Spend time sitting in silence with client.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is C

A.   Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B.   Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C.   Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D.   Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

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Correct Answer is A

Explanation

A. The CAGE questionnaire focuses on four key aspects related to alcohol use: efforts to Cut down, Annoyance with questions about drinking, feelings of Guilt about drinking, and using alcohol as an "Eye-opener" in the morning. Exploring these aspects in depth can provide valuable information about the client's relationship with alcohol and potential problems.

B. While information about consumption, liver enzymes, and gastrointestinal complaints is important for assessing alcohol-related issues, these are not specifically addressed by the CAGE questionnaire.
C. Cancer screening results, anger, gastritis, and daily alcohol intake are relevant to assessing the client's overall health and alcohol use but are not directly related to the questions asked in the
CAGE questionnaire.
D. While information about minimizing drinking, missing family events, guilt about drinking, and daily alcohol intake may provide insight into the client's alcohol use, these aspects are not specifically addressed by the questions in the CAGE questionnaire.

A. Numbness B. Poor decision making C. Crying D. Disbelief E. Irritability

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"c"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Numbness: Rape-trauma syndrome: Numbness can be a symptom of the acute phase of rape trauma syndrome, where individuals may experience emotional detachment or a sense of being emotionally overwhelmed.
- Poor decision making: Alcohol intoxication: Poor decision making is a common symptom of alcohol intoxication due to impaired judgment and cognitive function caused by alcohol consumption.
- Crying: occurs in both alcohol intoxication and rape-trauma syndrome. Crying is a common emotional response during the acute phase of rape-trauma syndrome as individuals may experience intense feelings of sadness, fear, or helplessness. Crying may also occur in individuals experiencing alcohol intoxication, especially if they become emotionally overwhelmed or as a result of disinhibition caused by alcohol consumption. - Disbelief: Disbelief or denial is a typical reaction in the acute phase of rape-trauma syndrome as individuals may struggle to come to terms with the reality of the traumatic event. - Irritability: Irritability can result from alcohol intoxication due to its effects on mood regulation and inhibition.
- Difficulty concentrating: Difficulty concentrating is a common symptom of alcohol intoxication due to its sedative effects on cognitive function. Individuals in the acute phase of rape-trauma syndrome may also experience difficulty concentrating as a result of heightened emotional arousal and intrusive thoughts related to the traumatic event.

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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Mark which behaviors might be related to alcohol intoxication, acute phase of rape- trauma syndrome, or both. Tick only 1 box.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"c"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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