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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Disrupting group activities is a concerning behavior but may not necessitate constant observation. The key is to assess the potential for harm to self or others.
Choice B rationale: Refusing antipsychotic medications is a significant concern, but it alone may not warrant constant observation. The nurse needs to assess the client's overall behavior and the potential for harm.
Choice C rationale: Wandering into clients' rooms poses a risk to the safety of both the client and others. This behavior indicates a need for constant observation to prevent harm or inappropriate interactions.
Choice D rationale: Talking with nonsensical words is a symptom of the client's mental health condition but may not be the sole criterion for constant observation. The nurse should assess the overall risk to safety.
Correct Answer is D
Explanation
Choice A rationale: Asking in a non-threatening manner why the client cut their own abdomen is an appropriate therapeutic communication technique but may not be the priority during a dressing change. Safety and hygiene are essential.
Choice B rationale: Providing detailed thorough explanations when cleansing the wound is valuable, but the nurse should prioritize the physical care and safety aspects of the dressing change.
Choice C rationale: Requesting another staff member to assist with the dressing change may be appropriate for some clients, but it may not be necessary for every situation. The nurse should be capable of performing the dressing change safely. Choice D rationale: Performing the dressing change in a non-judgmental manner is crucial. The nurse should focus on providing care in a sensitive and non-critical way to establish trust and ensure the client's physical well-being.
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