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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Keeping the head of the bed raised 45 degrees can help improve lung expansion and reduce the risk of aspiration, which is particularly important for patients who are intubated or receiving enteral nutrition. However, it is not the most important intervention for a patient with septic shock.
Choice B rationale
Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or parenteral nutrition, as these can increase blood glucose levels. However, it is not the most important intervention for a patient with septic shock.
Choice C rationale
Assessing the warmth of the patient’s extremities can provide information about peripheral perfusion and may be useful in monitoring the patient’s response to treatment. However, it is not the most important intervention for a patient with septic shock.
Choice D rationale
This is the correct answer. Maintaining strict intake and output is crucial in managing a patient with septic shock. Fluid balance is a key component of managing septic shock, and accurate intake and output measurements are essential for guiding fluid resuscitation and assessing the patient’s response to treatment.

A. Nadolol. B. Captopril. C. Digoxin. D. Hydrochlorothiazide.

Correct Answer is A

Explanation

Choice A rationale

Nadolol is a beta-blocker that can decrease heart rate and contractility, which can potentially exacerbate heart failure and lead to cardiogenic shock.

Choice B rationale

Captopril is an angiotensin-converting enzyme (ACE) inhibitor that is often used in the treatment of heart failure. It works by relaxing blood vessels and reducing the workload of the heart.

Choice C rationale

Digoxin is a cardiac glycoside that is used to treat heart failure and certain heart arrhythmias. It works by increasing the force of the heart’s contractions, which can improve heart function.

Choice D rationale

Hydrochlorothiazide is a diuretic that is often used in the treatment of heart failure. It works by helping the body get rid of excess fluid, which can reduce the workload of the heart.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

Correct Answer is A

Explanation

Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

The nurse is educating a patient who was admitted with a blood glucose level of 580 mg/dL on how to prevent complications related to diabetes mellitus. Which statement, if made by the patient, would indicate that they have understood the teaching?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure. Which intervention should the nurse include in the plan of care?

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Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

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?