NRSG347 QUIZZES AND VERIFIED SOLUTIONS

NRSG347 A simple tool the nurse can use to screen for alcoholism is the CAGE questionnaire. CAGE is an acronym that represents four questions it contains. What is the first question that the nurse should ask Matt? a) "Have people annoyed you by criticizing your drinking?" b) "Have you ever felt bad or guilty about your drinking?" c) "Have you ever thought that you should cut down on your drinking?" d) "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" ANSWER: "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.) Matt answers "yes" to two of the four questions on the CAGE questionnaire. What action should the nurse take next? a) Prepare the client for possible alcohol withdrawal b) Further assess the client's drinking behaviors c) Obtain blood alcohol content with a breathalyzer d) Obtain a urine drug screen for polysubstance use ANSWER: 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) If it is determined that Matt is dependent on alcohol, which information should the nurse obtain in order to predict the onset of withdrawal symptoms? a) The frequency with which the client drinks alcohol b) The last time the client consumed an alcoholic beverage c) The quantity of alcohol the client usually drinks d) Past withdrawal symptoms the client has experienced ANSWER: The last time the client consumed an alcoholic beverage (This information is important, and the answer can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 4 to 6 hours after substance use) The nurse completes the assessment and reports the findings to the healthcare provider (HCP). The HCP talks with Matt and decides to admit him to the crisis unit with an admitting diagnosis of alcohol dependency and depression with suicidal ideation. What data supports the need for admission to the hospital? a) Drinking alcohol and potential withdrawal b) Ineffective denial about severity of problem c) Elevated vital signs and liver disease d) Thought of wanting to jump off a bridge ANSWER: Thought of wanting to jump off a bridge (The client is at risk for self-harm because he has thoughts of jumping off a bridge. Risk for self-harm is a priority problem that requires hospitalization) When Matt is admitted to the Crisis Unit, the nurse understands that it is best to maintain a quiet, calm environment to help him relax and decrease nervous system irritability. The nurse must assign a room and search his belongings. Which items can the nurse allow Matt to keep in his room? (Select all that apply.) a) Unlaced tennis shoes b) Aftershave lotion c) Electronic book reader d) An electronic cigarette e) A personal photo ANSWER: -Unlaced tennis shoes (Matt can keep his tennis shoes. Tennis shoes without laces do not typically pose a threat)