The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care. Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter. 

Choice A rationale
While any positive response on the CAGE questionnaire could be a cause for concern and warrant further investigation, one positive response does not definitively indicate that the patient should seek help with alcohol addiction. The CAGE questionnaire is a screening tool used to identify potential problems with alcohol, but it is not diagnostic. A healthcare provider would need to conduct a more thorough assessment to diagnose alcohol addiction.
Choice B rationale
It is not necessary for all responses to the CAGE questionnaire to be positive in order to suggest alcohol dependence. The CAGE questionnaire is a screening tool, and while a greater number of positive responses increases the likelihood of alcohol dependence, it is not a requirement for all responses to be positive. A score of two or more is considered clinically significant.

Choice C rationale
The CAGE questionnaire is indeed a tool used to identify potential problems with alcohol, but it is not used to identify general substance abuse. The CAGE questionnaire specifically asks about feelings related to alcohol use. There are other screening tools available that are designed to identify issues with other substances.
Choice D rationale
This is the correct answer. The CAGE questionnaire is a validated screening tool that is widely used in clinical settings to detect alcoholism. It is considered positive, and suggestive of alcohol dependence, if two or more questions are answered affirmatively.

Choice A rationale

Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.