BSN 266 - HESI Case Study (Alcoholism) || Questions and Answers.
A client is accompanied to the ED by a police officer who found him standing on a bridge
threatening to jump. The client planned to jump off the bridge because significant other moved
out of their shared home & the client lost their job as a chef several days ago. The client has a
strong odor of alcohol on their breath but reports drinking only 4 beers in the last 12 hours. The
client denies using medications/illegal drugs within past 72 hours. The client is known to the
staff because of previous admissions related to alcohol abuse. The client is angry/uncooperative
& the nurses will not allow client to leave. The client states that they have felt sad for several
weeks which is the reason for drinking alcohol. The client reports sleeping 5-6 hours a night &
states their appetite is poor, resulting in significant weight loss over the past month. Physical
health problems include history of compromised liver function. correct answers "Have you ever
thought that you should cut down on your drinking?"
This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may
realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior.
When sober, an alcoholic may make a pledge to reduce consumption.
RATIONALE FOR INCORRECT:
"Have people annoyed you by criticizing your drinking?"
This is the second question of the questionnaire. In CAGE, A stands for annoyed. Often the
behaviors of alcoholics, especially when inebriated, are annoying to family and friends.
Frequently the alcoholic is unaware of the behavior and is angered when family and/or friends
complain.
"Have you ever felt bad or guilty about your drinking?"
This is the third question of the questionnaire. In CAGE, G stands for guilty. When sober,
alcoholics often experience feelings of embarrassment and guilt about behavior that occurred
while intoxicated.
"Have you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover?"
This is the fourth question in the questionnaire. In CAGE, E stands for eye-opener. Eye-opener is
a term used to describe the need to drink alcohol as soon as waking up to ward off or try to
eliminate a hangover. It is a serious indication of overconsumption.
,What is the first question that the nurse should ask?
"Have people annoyed you by criticizing your drinking?"
"Have you ever felt bad or guilty about your drinking?"
"Have you ever thought that you should cut down on your drinking?"
"Have you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover?" correct answers Further assess the client's drinking behaviors.
The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore,
further assessment is needed to make a diagnosis of alcoholism.
RATIONALE FOR INCORRECT:
The CAGE questionnaire is a screening tool that is used to identify individuals who may be
abusing alcohol. The nurse needs more information to determine if the client has an alcohol
addiction.
A breathalyzer is a screening tool used to determine recent alcohol use. The CAGE questionnaire
is used as a screening tool for alcohol abuse. The nurse needs more information to determine if
the client has an alcohol addiction.
A urine drug screen is a tool for alcohol or drug use. While this screening may become necessary
to determine if the client is using other drugs, the nurse needs more information to determine if
the client has an alcohol addiction.
The client answers "yes" to two of the four questions on the CAGE questionnaire. correct
answers
If it is determined the client is dependent on alcohol, which information should the nurse obtain
in order to predict the onset of withdrawal symptoms?
The frequency with which the client drinks alcohol.
The last time the client consumed an alcoholic beverage.
The quantity of alcohol the client usually drinks.
, Past withdrawal symptoms the client has experienced. correct answers The last time the client
consumed an alcoholic beverage.
This can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 6
to 8 hours after alcohol use.
RATIONALE FOR INCORRECT:
With increased frequency of alcohol consumption, tolerance is likely to develop, resulting in
withdrawal symptoms. By itself, frequency of drinking is not a good predictor of the onset of
withdrawal.
The quantity of alcohol the client usually drinks will not help the nurse predict the onset of
withdrawal symptoms. The client is likely to use denial, so a good rule of thumb is to double the
amount of reported intake.
The client's previous withdrawal experiences will not predict the onset of the current withdrawal
symptoms. If the client has experienced withdrawal in the past, it can help identify how the client
will experience current symptoms.
The nurse completes the assessment and reports the findings to the healthcare provider (HCP).
The HCP talks with the client who is admitted to the crisis unit with an admitting diagnosis of
alcohol dependency and depression with suicidal ideation. correct answers
Which data supports the need for admission to the hospital?
Drinking alcohol with potential withdrawal
Ineffective denail about severity of problem
Elevated vital signs and liver disease
Thoughts of wanting to jump off a bridge correct answers Thoughts of wanting to jump off a
bridge.
The client is at risk for self-harm, which is a priority problem that requires hospitalization.
RATIONALE FOR INCORRECT:
A client is accompanied to the ED by a police officer who found him standing on a bridge
threatening to jump. The client planned to jump off the bridge because significant other moved
out of their shared home & the client lost their job as a chef several days ago. The client has a
strong odor of alcohol on their breath but reports drinking only 4 beers in the last 12 hours. The
client denies using medications/illegal drugs within past 72 hours. The client is known to the
staff because of previous admissions related to alcohol abuse. The client is angry/uncooperative
& the nurses will not allow client to leave. The client states that they have felt sad for several
weeks which is the reason for drinking alcohol. The client reports sleeping 5-6 hours a night &
states their appetite is poor, resulting in significant weight loss over the past month. Physical
health problems include history of compromised liver function. correct answers "Have you ever
thought that you should cut down on your drinking?"
This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may
realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior.
When sober, an alcoholic may make a pledge to reduce consumption.
RATIONALE FOR INCORRECT:
"Have people annoyed you by criticizing your drinking?"
This is the second question of the questionnaire. In CAGE, A stands for annoyed. Often the
behaviors of alcoholics, especially when inebriated, are annoying to family and friends.
Frequently the alcoholic is unaware of the behavior and is angered when family and/or friends
complain.
"Have you ever felt bad or guilty about your drinking?"
This is the third question of the questionnaire. In CAGE, G stands for guilty. When sober,
alcoholics often experience feelings of embarrassment and guilt about behavior that occurred
while intoxicated.
"Have you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover?"
This is the fourth question in the questionnaire. In CAGE, E stands for eye-opener. Eye-opener is
a term used to describe the need to drink alcohol as soon as waking up to ward off or try to
eliminate a hangover. It is a serious indication of overconsumption.
,What is the first question that the nurse should ask?
"Have people annoyed you by criticizing your drinking?"
"Have you ever felt bad or guilty about your drinking?"
"Have you ever thought that you should cut down on your drinking?"
"Have you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover?" correct answers Further assess the client's drinking behaviors.
The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore,
further assessment is needed to make a diagnosis of alcoholism.
RATIONALE FOR INCORRECT:
The CAGE questionnaire is a screening tool that is used to identify individuals who may be
abusing alcohol. The nurse needs more information to determine if the client has an alcohol
addiction.
A breathalyzer is a screening tool used to determine recent alcohol use. The CAGE questionnaire
is used as a screening tool for alcohol abuse. The nurse needs more information to determine if
the client has an alcohol addiction.
A urine drug screen is a tool for alcohol or drug use. While this screening may become necessary
to determine if the client is using other drugs, the nurse needs more information to determine if
the client has an alcohol addiction.
The client answers "yes" to two of the four questions on the CAGE questionnaire. correct
answers
If it is determined the client is dependent on alcohol, which information should the nurse obtain
in order to predict the onset of withdrawal symptoms?
The frequency with which the client drinks alcohol.
The last time the client consumed an alcoholic beverage.
The quantity of alcohol the client usually drinks.
, Past withdrawal symptoms the client has experienced. correct answers The last time the client
consumed an alcoholic beverage.
This can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 6
to 8 hours after alcohol use.
RATIONALE FOR INCORRECT:
With increased frequency of alcohol consumption, tolerance is likely to develop, resulting in
withdrawal symptoms. By itself, frequency of drinking is not a good predictor of the onset of
withdrawal.
The quantity of alcohol the client usually drinks will not help the nurse predict the onset of
withdrawal symptoms. The client is likely to use denial, so a good rule of thumb is to double the
amount of reported intake.
The client's previous withdrawal experiences will not predict the onset of the current withdrawal
symptoms. If the client has experienced withdrawal in the past, it can help identify how the client
will experience current symptoms.
The nurse completes the assessment and reports the findings to the healthcare provider (HCP).
The HCP talks with the client who is admitted to the crisis unit with an admitting diagnosis of
alcohol dependency and depression with suicidal ideation. correct answers
Which data supports the need for admission to the hospital?
Drinking alcohol with potential withdrawal
Ineffective denail about severity of problem
Elevated vital signs and liver disease
Thoughts of wanting to jump off a bridge correct answers Thoughts of wanting to jump off a
bridge.
The client is at risk for self-harm, which is a priority problem that requires hospitalization.
RATIONALE FOR INCORRECT:
