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.
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Related Questions
Correct Answer is D
Explanation
A. Social isolation R/T inability to relate to others
While social isolation may be a concern for individuals with paranoid personality disorder, the immediate safety risk associated with the disorder is more related to the potential for violence. Therefore, addressing the risk of violence takes precedence.
B. Risk for suicide R/T altered thought:
Paranoid personality disorder is not typically associated with a high risk of suicide. Individuals with this disorder are more likely to pose a risk to others due to their suspicious thoughts and mistrust. Suicide risk assessments are crucial but may not be the top priority in this specific case.
C. Altered sensory perception R/T increased levels of anxiety:
Paranoid personality disorder does involve heightened levels of anxiety, but altered sensory perception is not a primary characteristic of the disorder. Addressing anxiety is important, but the potential for violence toward others is a more immediate concern.
D. Risk for violence: directed toward others R/T suspicious thoughts:
This is the most appropriate priority. Individuals with paranoid personality disorder may have intense mistrust and suspicion, leading to the potential for aggressive or violent behavior directed toward others. Prioritizing safety and preventing harm to others is crucial in the care of clients with this disorder.
Correct Answer is C
Explanation
A. By setting punishments for clients who violate the community rules: This approach is more authoritarian than democratic. In a democratic milieu, the emphasis is on collaboration, shared decision-making, and equal participation, rather than imposing punishments.
B. By setting expectations wherein all clients are not treated on an equal basis: This approach would be contrary to the principles of a democratic milieu. The democratic model promotes equality, inclusion, and the involvement of all clients in decision-making.
C. By setting expectations wherein all clients are treated on an equal basis: This is the correct answer. In a democratic milieu, all clients are encouraged to participate equally in decision-making processes, express their opinions, and contribute to the therapeutic community. This fosters a sense of empowerment and shared responsibility.
D. By dealing with inappropriate behaviors as they occur: While addressing inappropriate behaviors is important in any therapeutic environment, the emphasis on a democratic form of self-government goes beyond reacting to behaviors. It involves actively engaging clients in the decision-making process and promoting a collaborative and supportive community.
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