While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?
MAST
CAGE
CIWA
DMSE
The Correct Answer is C
A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.
B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While monitoring sodium levels can be important for clients on certain
medications, it is not a primary concern with lamotrigine. The main concern is the potential for a serious rash.
B) Correct. Lamotrigine is associated with a risk of a severe skin reaction called Stevens Johnson syndrome. If a client experiences any rash while taking lamotrigine, it is crucial to notify a
healthcare provider immediately.
C) Incorrect. While monitoring weight and potential changes in appetite are important aspects of overall health, it is not a specific teaching point for lamotrigine.
D) Incorrect. While it is important for individuals of childbearing age to discuss pregnancy plans and contraceptive methods with their healthcare provider, it is not the primary teaching point specific to lamotrigine.
Correct Answer is B
Explanation
A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.
B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.
C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.
D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.
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