While conducting an admission interview with a client in the emergency department, the nurse suspects that the client may be a heavy user of alcohol
Which of the following assessment tools can help the nurse screen for potentially problematic alcohol use?
A) PERSONS
B) CAGE
C) CIWA-Ar
D) MSE
Ans: B
Feedback:
A short screening tool such as the CAGE screening questionnaire can be useful at the outset to identify whether alcohol use is problematic. Once alcohol withdrawal is suspected, a screening tool such as the CIWA-Ar can assist nurses to identify the severity of symptoms.
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An overweight male patient rips off his hospital gown, throws it out the door, and shouts, "I'm not wearing this stupid gown. It is too small, too short, and exposes my backside to the world." The nurse's best approach would be to:
a. remind patient of the need to wear the gown for convenience in care. b. confer with the patient for methods to ac-quire a larger gown. c. replace the torn gown with another. d. inform the charge nurse of the hostile be-havior.
Nurses at a homeless clinic are concerned that homeless clients rarely return to have the nurses assess the findings of their tuberculosis (TB) skin tests. Which of the following is the most appropriate policy for the clinic to have regarding the screenin
a. Call all homeless clients 48 hours after TB skin testing to remind them to return to the clinic for test interpretation. b. Have homeless individuals read their TB skin test, if necessary, and mail in results on a postage-paid card coded to protect privacy. c. Re-administer the TB skin test if the client returns later than scheduled for test interpretation. d. Routinely refer all homeless clients for chest x-rays.
A nurse psychotherapist works with an anxious, dependent patient. The therapeutic strategy most consistent with the framework of psychoanalytic psychotherapy is:
a. emphasizing medication compliance b. identifying the patient's strengths and assets c. offering psychoeducational materials and groups d. focusing on feelings developed by the patient toward the nurse
When the nurse is caring for a patient who reports he has blood that begins when he initiates the urine stream and then abates. Based on underlying pathophysiology, the nurse concludes that the hematuria is occurring in which location?
a. In the kidney b. Above the neck of the bladder c. In the neck of the bladder d. In the urethra