While conducting an admission interview with a client, the nurse suspects the client may be in alcohol withdrawal. Which screening tool can help the nurse identify the severity of withdrawal symptoms?
MAST
CAGE
CIWA
DMSE
The Correct Answer is C
A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.
B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This outcome is specific, measurable, and timebound. It addresses the client's impaired social interactions and sets a realistic expectation for improvement within a short timeframe.
B. While this outcome is specific, it may not be achievable within a short timeframe and may not directly address the issue of egocentrism.
C. This outcome focuses on verbalization but may not necessarily lead to actual interaction or address the issue of egocentrism.
D. While this outcome is relevant, it is not as specific or timebound as option A.
Correct Answer is A
Explanation
A) Correct. Amitriptyline, like other tricyclic antidepressants, can cause orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing.
B) Incorrect. Diarrhea is not a common side effect of amitriptyline.
C) Incorrect. Weight gain is more commonly associated with amitriptyline, not weight loss.
D) Incorrect. Excessive salivation is not a typical side effect of amitriptyline.
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