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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A schizophrenic episode Schizophrenic episodes are characterized by a complex interplay of symptoms including delusions, hallucinations, disorganized thinking, and altered perceptions. While the client is experiencing altered perceptions, the sudden onset and specific description are more indicative of hallucinogen ingestion.

B. Hallucinogen ingestion The client's description of altered perception, feeling outside of their own body, and visual distortions are indicative of hallucinogen ingestion. This class of substances can cause profound alterations in perception, leading to hallucinations and distorted sensory experiences. The slightly elevated vital signs may be a physiological response to the effects of the hallucinogen.

C. Opium intoxication Opium is an opioid and its effects are characterized by sedation, respiratory depression, and miosis (pupil constriction). The client's description of altered perception and feeling outside of their body are not typical of opium intoxication.

D. Cocaine overdose Cocaine is a stimulant and its effects are characterized by increased heart rate, blood pressure, and hyperarousal. The client's description of altered perception and feeling outside of their body are not typical of cocaine overdose.

A. Encourage participation in various physical activities. B. Encourage participation in a group card game. C. Encourage participation in a BINGO game. D. Encourage the creation of a new interactive game for the unit.

Correct Answer is A

Explanation

A) Correct. Encouraging participation in physical activities can help channel excess energy and agitation associated with manic episodes.

B) Incorrect. Group card games may not provide an outlet for the high energy level typically seen in a manic episode.

C) Incorrect. While Bingo is a social activity, it may not be sufficient to address the high energy and potential restlessness seen in a manic episode.

D) Incorrect. Creating a new interactive game may not be feasible or appropriate in the acute setting, and it may not effectively address the client's current needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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