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 D
Explanation
A. Risperidone (Risperdal):
Risperidone is an atypical antipsychotic and generally has a lower propensity for causing anticholinergic side effects compared to typical antipsychotics.
B. Lithium (Lithobid):
Lithium is a mood stabilizer used primarily for bipolar disorder and does not typically cause anticholinergic side effects.
C. Buspirone (Buspar):
Buspirone is an anxiolytic medication and does not have significant anticholinergic properties. It tends to have fewer side effects compared to other medications used for anxiety.
D. Fluphenazine (Prolixin):
Fluphenazine is a typical antipsychotic medication and belongs to the phenothiazine class, which is known to have notable anticholinergic effects. These effects can include dry mouth, constipation, blurred vision, urinary retention, and cognitive impairment.
Correct Answer is D
Explanation
A. Implement the client's behavioral modification plan:
While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.
B. Document the size and location of the cuts:
Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.
C. Administer a tetanus antitoxin:
Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.
D. Inspect the cuts for debris:
This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.
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