The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Cancer screening results, anger, gastritis, daily alcohol intake.

Consumption, liver enzyme, gastrointestinal complaints, and bleeding.

Efforts to cut down, annoyance with questions, guilt, and drinking as an "Eye-opener."

Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.

Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."

Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.

Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.

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Correct Answer is C

Explanation

Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.

A. Request backup from the staff. B. Stand in the doorway. C. Provide for personal space. D. Encourage the client to sit down.

Correct Answer is C

Explanation

Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.

Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.

Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.

Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.

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The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is C

Explanation

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Correct Answer is C

Explanation

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The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

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Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

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