The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query.
What interpretation should the nurse provide to the patient?
One positive response indicates the patient should seek help with alcohol addiction.
All responses to the CAGE Questionnaire must be positive to suggest alcohol dependence.
The CAGE Questionnaire is a tool used to identify general substance abuse.
At least two positive responses are strongly suggestive of alcohol dependence.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
After a gastric endoscopy, it’s common for patients to experience a sore throat. This is due to the passage of the endoscope through the throat during the procedure. The discomfort is usually temporary and can be relieved with lozenges or gargling with warm salt water.
Choice B rationale
While headaches can occur after procedures that involve sedation, they are not commonly associated with gastric endoscopy specifically. Therefore, while it’s important to monitor for headaches, they are not a typical post-procedure problem following a gastric endoscopy.
Choice C rationale
Aching legs are not a common problem following a gastric endoscopy. The procedure primarily involves the upper gastrointestinal tract, and does not directly affect the legs.
Choice D rationale
Nausea can occur after a gastric endoscopy, but it is more commonly associated with the sedation used during the procedure rather than the procedure itself. If nausea does occur, it can be managed with antiemetic medications.
Correct Answer is B
Explanation
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.
Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.
Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.
Choice D rationale
Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.
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