Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Reports difficulties with short term memory since a traumatic brain injury.

Medical history includes that the client was recently sexually assaulted.

Describes self as a social drinker who drinks alcoholic beverages daily.

Client's medication history includes the frequent use of antidepressants.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.

Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.

Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.

Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.

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Correct Answer is C

Explanation

Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.

Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.

Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.

Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.

A. Individual addiction counseling. B. Initiate disulfiram teaching. C. Thiamine administration. D. Nutrition referral.

Correct Answer is C

Explanation

Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.

Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.

Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.

Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.

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Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

Correct Answer is C

Explanation

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

A client with chronic alcoholism receives a prescription for disulfiram. Which client statement indicates that this medication teaching has been effective?

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?