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The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- B. Minimizes drinking frequently misses family events, guilt about drinking, and amount of daily intake.
- C. Cancer screening results, anger, gastritis, daily alcohol intake.
- D. Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener”.
Correct Answer: D
Rationale: The correct answer is D. The CAGE questionnaire is a screening tool used to identify alcohol abuse. Each letter in CAGE stands for a key question: "Cut down," "Annoyed by criticism," "Guilty feelings," and "Eye-opener." These questions help assess the client's alcohol-related behaviors and attitudes. Exploring the client's efforts to cut down on drinking indicates acknowledgment of a potential issue. Annoyance with questions may suggest defensiveness or denial. Feelings of guilt can indicate internal conflict about drinking, and using alcohol as an "Eye-opener" can signal dependence. Therefore, delving into these specific areas can provide valuable insights into the client's alcohol use patterns and potential problems. Choices A, B, and C are incorrect as they do not align with the purpose of the CAGE questionnaire in identifying alcohol abuse behaviors and attitudes.
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A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?
- A. Pan-seared catfish.
- B. Peperoni pizza.
- C. Deep fried shrimp.
- D. Beef trips with gravy.
Correct Answer: D
Rationale: The correct answer is D: Beef tips with gravy. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with tyramine-rich foods, potentially causing hypertensive crisis. Beef tips with gravy contain high levels of tyramine, which can lead to a dangerous spike in blood pressure when combined with MAOIs. Pan-seared catfish, pepperoni pizza, and deep-fried shrimp are not typically high in tyramine and do not pose the same risk. Therefore, the RN should instruct the client to avoid beef tips with gravy to prevent complications.
Which statement made by a patient prescribed bupropion (Wellbutrin) demonstrates that the medication education the patient received was effective? Select all that apply.
- A. I hope Wellbutrin will help my depression and also help me to finally quit smoking.
- B. I’m happy to hear that I won’t need to worry too much about weight gain.
- C. It’s okay to take Wellbutrin since I haven’t had a seizure in 6 months.
- D. I need to be careful about driving since the medication could make me drowsy.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates the patient understands the dual purpose of bupropion - treating depression and aiding smoking cessation. This indicates comprehension of the medication's intended effects. Choice B is incorrect as weight loss is a common side effect, not weight gain. Choice C is incorrect as a history of seizures is a contraindication for bupropion. Choice D is incorrect as bupropion is not known to cause drowsiness.
A client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: The correct answer is A: Set a specific limit on the number of times the client can check the door. This intervention helps establish boundaries and structure for the client, which can assist in reducing compulsive behaviors. By setting a specific limit, the client is encouraged to gradually decrease the checking behavior and learn to cope with the anxiety associated with uncertainty. This approach promotes independence and empowerment for the client.
Choice B is incorrect because finding an alternative activity does not directly address the obsessive checking behavior. Choice C is incorrect as providing consistent reassurance reinforces the compulsive behavior. Choice D is incorrect because ignoring the behavior does not actively address or help decrease the compulsive checking.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: The correct answer is C: Avoid recognizing the behavior. Echolalia is the repetition of words or phrases spoken by others, common in schizophrenia. By not reinforcing or acknowledging the behavior, the client may eventually stop. Isolating the client (Choice A) may lead to feelings of rejection. Administering a sedative (Choice B) may not address the underlying behavior. Escorting the client to his room (Choice D) does not address the echolalia directly.
Pablo is a homeless adult who has no family connection. Pablo passed out on the street and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply.
- A. Intermittent supervision is available in inpatient settings.
- B. He requires stabilization of multiple symptoms.
- C. He has nutritional and self-care needs.
- D. Medication adherence will be mandated.
Correct Answer: A
Rationale: The correct answer is A: Intermittent supervision is available in inpatient settings. In an inpatient treatment setting, Pablo can receive continuous monitoring and supervision, ensuring his safety and well-being. This is crucial for someone like Pablo who is homeless, has substance use issues, and expressed a wish to die. Inpatient treatment can provide a controlled environment where his physical and mental health can be closely monitored, and immediate interventions can be implemented if needed.
Incorrect choices:
B: While stabilization of multiple symptoms is important, the key factor here is the need for constant supervision, which is better provided in an inpatient setting.
C: Although nutritional and self-care needs are important, the primary concern in this case is Pablo's mental health and safety, which can be better addressed in an inpatient setting.
D: While medication adherence is important, it is not the primary reason for recommending inpatient treatment for Pablo. The need for supervision and monitoring takes precedence.