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.
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Related Questions
Correct Answer is B
Explanation
A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.
B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.
C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.
Correct Answer is D
Explanation
A. "Lab work is only needed at the start of taking the medication." This statement is incorrect. Regular monitoring of lithium levels and kidney function through lab work is crucial for ensuring the medication's effectiveness and preventing potential toxicity.
B. "Once I feel better, I will not need to take this medication anymore." This statement is incorrect. Lithium is typically prescribed for long-term maintenance in bipolar disorder to prevent relapses and stabilize mood.
C. "There is a chance I may become addicted to this medication." This statement is incorrect. Lithium is not addictive. It is a mood stabilizer used to manage bipolar disorder.
D. "I need to be aware of situations that may cause dehydration." This statement demonstrates an understanding of an important consideration with lithium. Dehydration can lead to an increase in lithium levels in the body, potentially leading to toxicity. It's important for clients taking lithium to stay well hydrated and be cautious in situations that may lead to dehydration.
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