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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.

A. "As depression lifts, physical energy becomes available to carry out suicide." B. "Suicide may be precipitated by a variety of internal and external events." C. "Suicidal clients have difficulty using social supports." D. "Suicide is an impulsive act that has no warning."

Correct Answer is A

Explanation

A. "As depression lifts, physical energy becomes available to carry out suicide." This statement highlights a critical consideration in the care of severely depressed clients. When a client's depression starts to improve due to antidepressant therapy, there may be a period where they have increased energy but have not yet gained full relief from their depressive thoughts. This can potentially increase the risk of carrying out suicidal thoughts or plans.

B. "Suicide may be precipitated by a variety of internal and external events." While this statement is true, it does not specifically address the importance of monitoring a client during antidepressant therapy.

C. "Suicidal clients have difficulty using social supports." This statement acknowledges a potential challenge for clients who are experiencing suicidal thoughts, but it does not directly relate to the need for close monitoring during antidepressant therapy.

D. "Suicide is an impulsive act that has no warning." This statement is not entirely accurate. While some suicides can be impulsive, many individuals give warning signs or exhibit changes in behavior before attempting suicide.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Correct Answer is D

Explanation

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?

Correct Answer is A

Explanation

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