Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Reports difficulties with short term memory since a traumatic brain injury.

Medical history includes that the client was recently sexually assaulted.

Describes self as a social drinker who drinks alcoholic beverages daily.

Client's medication history includes the frequent use of antidepressants.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.

Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.

Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.

Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.

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Correct Answer is C

Explanation

Choice A rationale: Providing teaching on the symptoms of substance use dependence may be appropriate, but supporting the client's desire for positive changes is the immediate priority.

Choice B rationale: Advising the client to reschedule is not supportive of their current motivation for change.

Choice C rationale: Supporting the client to list small behavioral changes needed aligns with the client's expressed desire for a healthier lifestyle and is consistent with motivational interviewing techniques.

Choice D rationale: Explaining specific relapse prevention skills may be useful later in the recovery process, but initially supporting the client's motivation for change is the priority.

A. Speak calmly to the client stating assurance of safety. B. Attempt to distract to another focus or activity. C. Help the client to identify thoughts that may be triggers. D. Explore past behaviors that have provided relief.

Correct Answer is A

Explanation

Choice A rationale: Speaking calmly and assuring the client of safety is a therapeutic intervention for managing severe anxiety and panic. It helps provide a sense of reassurance and safety to the client during an acute anxious episode.

Choice B rationale: Attempting to distract the client can be helpful in some situations, but in severe anxiety, the focus should initially be on providing a sense of safety and addressing immediate distress.

Choice C rationale: Helping the client identify thoughts is more appropriate during less acute moments or in the context of cognitive-behavioral therapy. In severe anxiety, the immediate focus is on providing support and reassurance.

Choice D rationale: Exploring past behaviors may be part of a comprehensive assessment but is not the first priority during an acute episode of severe anxiety.

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Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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