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?
1. What is the first question that the
D. Have you ever had a drink first think in the morning to steady your
nurse should ask Nick (CAGE)?
nerves or get rid of a hangover?
ANS: C
A. Take precautions for possible alcohol withdrawal
B. Further assess the client's drinking behaviors
C. Obtain blood alcohol content with a breathalyzer
2. Nick answers yes to 2/4 D. obtain a urine drug screen for polysubstance use
questions, what should the nurse
do next? Ans: B
Rationale: further assessment is needed to make a diagnosis of
alcoholism, because the CAGE questionnaire is only a screening tool
to identify alcohol abuse.
A How often do you usually drink?
B when did you last have something to drink?
C How much alcohol do you usually have?
3. Which question is most likely to
D What is your experience with withdrawal?
assist with prediction of the onset
of withdrawal symptoms if the client
ans: B
is dependent on alcohol?
rationale: This question is important, and the answer can help with
prediction of the onset of withdrawal symptoms, because withdrawal
can begin as early as 4-6 hours after substance use.
, A. Drinking alcohol and potential withdrawal
B. Ineffective denial about severity of problem
4. The HCP admits Nick with a dx of C. Elevated vital signs and liver disease
alcohol dependency and D Thoughts of wanting to jump off a bridge
depression with suicidal ideation.
What data supports the need for ans: D
admission to the hospital? rationale: The client is at risk for self-harm because he had thoughts of
jumping off the bridge. Risk for self-harm is a priority problem that
requires hospitalization.
A. unlaced tennis shoes
B aftershave lotion
C Home vitamins
D Pack of cigarettes
5. Which item(s) can the nurse allow
E A personal photo
Nick to keep in his room? SATA
ans: AE
rationale: aftershave lotion contains alcohol, meds must be sent to
pharmacy, pt cant smoke IN the hospital
A. drinking alcohol to ineffectively cope
B Ineffective denial about severity of problem
6. What is the priority nursing C. Elevated vital signs and liver disease
problem for the initial crisis plan? D Thoughts of wanting to jump off a bridge
ans: D
B. Have you ever felt bad or guilty about your drinking?
C. Have you ever thought that you should cut down on your drinking?
1. What is the first question that the
D. Have you ever had a drink first think in the morning to steady your
nurse should ask Nick (CAGE)?
nerves or get rid of a hangover?
ANS: C
A. Take precautions for possible alcohol withdrawal
B. Further assess the client's drinking behaviors
C. Obtain blood alcohol content with a breathalyzer
2. Nick answers yes to 2/4 D. obtain a urine drug screen for polysubstance use
questions, what should the nurse
do next? Ans: B
Rationale: further assessment is needed to make a diagnosis of
alcoholism, because the CAGE questionnaire is only a screening tool
to identify alcohol abuse.
A How often do you usually drink?
B when did you last have something to drink?
C How much alcohol do you usually have?
3. Which question is most likely to
D What is your experience with withdrawal?
assist with prediction of the onset
of withdrawal symptoms if the client
ans: B
is dependent on alcohol?
rationale: This question is important, and the answer can help with
prediction of the onset of withdrawal symptoms, because withdrawal
can begin as early as 4-6 hours after substance use.
, A. Drinking alcohol and potential withdrawal
B. Ineffective denial about severity of problem
4. The HCP admits Nick with a dx of C. Elevated vital signs and liver disease
alcohol dependency and D Thoughts of wanting to jump off a bridge
depression with suicidal ideation.
What data supports the need for ans: D
admission to the hospital? rationale: The client is at risk for self-harm because he had thoughts of
jumping off the bridge. Risk for self-harm is a priority problem that
requires hospitalization.
A. unlaced tennis shoes
B aftershave lotion
C Home vitamins
D Pack of cigarettes
5. Which item(s) can the nurse allow
E A personal photo
Nick to keep in his room? SATA
ans: AE
rationale: aftershave lotion contains alcohol, meds must be sent to
pharmacy, pt cant smoke IN the hospital
A. drinking alcohol to ineffectively cope
B Ineffective denial about severity of problem
6. What is the priority nursing C. Elevated vital signs and liver disease
problem for the initial crisis plan? D Thoughts of wanting to jump off a bridge
ans: D
