The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?
By using a screening tool such as the CAGE questionnaire
By asking directly if the client has ever had a problem with alcohol
By holistically assessing the client using the CINA scale
By referring the client for physician evaluation
The Correct Answer is A
A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.
B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.
C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.
D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A nurse asks a client if they have any cultural beliefs the nurse needs to be aware of: This example demonstrates cultural competence as the nurse is actively seeking information about the client's cultural beliefs, practices, and preferences. It reflects an understanding that cultural factors can influence healthcare and the client-nurse relationship.
B. A nurse tells a client about the nurse's own cultural background: While sharing cultural information can be a part of building rapport, the focus of cultural competence is on understanding and respecting the client's cultural background, not necessarily sharing the nurse's own cultural background.
C. A nurse observes a client's actions and reports they do not see any cultural practices: This approach is limited, as cultural practices may not always be visible or evident in a clinical setting. Cultural competence involves actively seeking information from the client rather than making assumptions based on observations.
D. A nurse checks a client's chart for any notes on culture: While reviewing a client's chart for cultural information is part of cultural competence, it is not a complete approach. Direct communication with the client about their cultural beliefs and preferences is essential for a comprehensive understanding.
Correct Answer is A
Explanation
A. Psychosocial history:
This includes information about the client's social, cultural, family, educational, and occupational background. It provides insights into the client's life circumstances, stressors, support systems, and overall psychosocial context. This information is crucial for understanding the context in which mental health symptoms may be occurring.
B. Vaccine history:
Vaccine history is not typically a primary factor in diagnosing mental health disorders. It is more relevant to preventive care and physical health.
C. History of allergies:
Allergies are primarily related to physical health and may not play a direct role in the diagnosis of mental health disorders.
D. Surgical history:
Surgical history is relevant to physical health conditions and is not a primary consideration in the diagnosis of mental health disorders.
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