One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

a. The CAGE Questionnaire

Explanation of Choices

Choice A Reason: The CAGE Questionnaire

The CAGE Questionnaire is a widely used screening tool for identifying potential alcohol use disorders. It consists of four questions that focus on key aspects of alcohol dependency: Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers (drinking first thing in the morning). This tool is quick to administer and has been validated in various clinical settings, making it an effective choice for initial screening of alcohol problems. The CAGE Questionnaire is particularly useful in preoperative assessments to identify patients who may be at risk for alcohol-related complications during and after surgery.

Choice B Reason: The Abnormal Involuntary Movement Scale

The Abnormal Involuntary Movement Scale (AIMS) is used to assess the severity of tardive dyskinesia and other involuntary movements, typically in patients taking antipsychotic medications. It is not designed to screen for alcohol use disorders. Therefore, it would not be appropriate for evaluating a client suspected of having a drinking problem.

Choice C Reason: The Clinical Institute Withdrawal Assessment Scale

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a tool used to assess the severity of alcohol withdrawal symptoms. While it is valuable for managing patients already known to have alcohol dependence, it is not a primary screening tool for identifying alcohol use disorders. The CIWA-Ar is more appropriate for monitoring patients during detoxification rather than initial screening.

Choice D Reason: Refer the Client for Physician Evaluation

Referring the client for a physician evaluation is a reasonable step if the nurse suspects a drinking problem. However, using a validated screening tool like the CAGE Questionnaire can provide immediate, actionable information that can guide the next steps in care. The CAGE Questionnaire can help determine the severity of the problem and whether a referral to a specialist is necessary.

Choice A Reason: Their full therapeutic potential may not be reached until 4 weeks

This statement is correct. Tricyclic antidepressants (TCAs) often take several weeks to reach their full therapeutic effect. Patients may start to notice some improvement within one to two weeks, but it can take up to four weeks or longer for the full benefits to be realized1. This delayed onset is due to the time it takes for the medication to build up in the system and exert its effects on neurotransmitter levels.

Choice B Reason: Aged cheese should not be eaten while taking them

This statement is incorrect. The dietary restriction of avoiding aged cheese is associated with monoamine oxidase inhibitors (MAOIs), not tricyclic antidepressants. MAOIs can cause dangerous interactions with tyramine, a substance found in aged cheese and other foods, leading to hypertensive crises. TCAs do not have this dietary restriction.

Choice C Reason: They should not be given with antianxiety agents

This statement is incorrect. Tricyclic antidepressants can be used in conjunction with antianxiety agents under medical supervision. However, it is important to monitor for potential interactions and side effects. The combination can be beneficial for patients with comorbid depression and anxiety disorders.

Choice D Reason: They may cause hypomania or recent memory impairment

This statement is partially correct but not the best indicator of understanding. While TCAs can cause side effects such as memory impairment and, in rare cases, hypomania, these are not the primary concerns when teaching about the medication. The focus should be on understanding the therapeutic timeline and common side effects.