The CAGE questionnaire asks four questions and is a widely used tool to screen for alcoholism. Which of the four questions included in the CAGE questionnaire is most indicative of alcoholism?

The palliative care nurse is admitting a client who has metastatic bone cancer and is unable to eat or drink without immediate nausea and vomiting. The client is complaining of pain at 9 on a 0 to 10 pain scale, and the vital signs are: heart rate 99 beats/minute, respirations 38 breaths/minute, oxygen saturation 95%, and blood pressure 110/80 mm Hg. Which intervention should the nurse implement?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

The nurse includes the problem of “Risk for infection” in the plan of care for a client with myelosuppression. Which laboratory value provides the greatest support for this nursing problem?

Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.69 to 11.17 mmol/L)], Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)], Red Blood Cell Count (RBC) [4.2 to 5.4 x 10⁶/µL (4.2 to 5.4 x 10¹²/L)], White Blood Cell (WBC) [5,000 to 10,000/mm³ (5 to 10 x 10⁹/L)].

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “Improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse?

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

An adult male who is admitted to the mental health clinic is alert and oriented to person, place, time, and situation. His affect is blunted, his mood dysphoric, and the nurse identifies his responses as tangential with a paranoid theme when he states, “I have a chip inside my head that is speaking to me.” Based on these assessment findings, which nursing problem is best to include in this client’s initial plan of care?

A client with a history of deep vein thrombosis (DVT) is receiving a continuous IV heparin infusion. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. Which action should the nurse take? Reference Range: aPTT [25 to 35 seconds, therapeutic range for heparin 1.5 to 2.5 times baseline, approximately 38 to 88 seconds].

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].