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The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?
- A. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener'
- B. Consumption, liver enzyme, gastrointestinal complaints and bleeding
- C. Cancer screening results, anger, gastritis, daily alcohol intake
- D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake
Correct Answer: A
Rationale: The CAGE questionnaire focuses on four key aspects: efforts to Cut down, Annoyance with questions, Guilt about drinking, and Eye-opener use. Exploring these provides insight into potential alcohol problems. Other options include relevant aspects but are not specific to the CAGE questionnaire.
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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The snakes on the wall are going to eat me
- B. The nurse at night is trying to poison me with pills
- C. The voices are telling me to kill the next person I see
- D. The fire is burning my skin away right now
- E. None
- F. None
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should plan to participate in group or individual therapy while at college
- B. The client's serum lithium levels should be routinely evaluated
- C. The client should be aware of the signs and symptoms of his illness
- D. Despite the illness, the client should be able to live away from home
Correct Answer: B
Rationale: Lithium therapy requires regular monitoring of serum levels to ensure therapeutic efficacy and prevent toxicity, especially during transitions like starting college. Therapy and symptom awareness are important but secondary to lithium level monitoring. Independence is a goal but not the primary focus.
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
What symptoms are consistent with long-term rape trauma? Select all that apply.
- A. Social withdrawal
- B. Exaggerated startle response
- C. Intrusive thoughts
- D. Avoidance of places associated with the assault
Correct Answer: A,B,C,D
Rationale: A: Social withdrawal reflects ongoing distress. B: Exaggerated startle response persists post-trauma. C: Intrusive thoughts are unwanted trauma-related memories. D: Avoidance of trauma-associated places is a protective mechanism. All are hallmark long-term symptoms of rape-trauma syndrome.
When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?
- A. Involve client in daily exercise program
- B. Ask the client to describe her depression
- C. Spend time sitting in silence with client
- D. Observe for signs of possible psychosis
Correct Answer: C
Rationale: Spending time sitting in silence with the client provides a supportive presence without pressure for immediate responses, which is helpful for depression-related delays in communication. Exercise may be beneficial but does not address delayed responses directly. Asking about depression is useful for assessment but not immediate needs. Observing for psychosis is not indicated unless other symptoms are present.