Nokea
The nurse uses the CAGE questionnaire to assess a patient. The nurse suspects the patient is an alcoholic if there are affirmative answers for items on the questionnaire.
Correct Answer: two
Rationale: An affirmative answer on two or more questions on the CAGE questionnaire is reason to assess more closely for possible alcohol abuse.
You may also like to solve these questions
If the patient tells the nurse, 'I'm not an alcoholic. I can stop whenever I want to,' what should be the nurse's most therapeutic response?
- A. Well, why don't you?
- B. Hasn't alcohol use interfered with your employment?
- C. A positive attitude like that is a good start.
- D. What would you call alcoholism?
Correct Answer: B
Rationale: When the addicted person presents in denial, the nurse should use techniques to set limits on that behavior.
What should the nurse do to decrease the damage of bruxism seen in a patient who has been abusing the drug ecstasy?
- A. Turn the patient to his right side.
- B. Elevate the head of the bed 30 degrees.
- C. Provide the patient with a pacifier.
- D. Administer a muscle relaxant.
Correct Answer: C
Rationale: The use of an infant pacifier will reduce the damage to the teeth for a patient who is manifesting bruxism (grinding of the teeth).
A 22-year-old patient presents in the emergency department with the characteristics of severe Parkinson disease. The nurse should suspect an overdose of what drug?
- A. Marijuana
- B. Cocaine
- C. Amphetamines
- D. Valium
Correct Answer: C
Rationale: Over time, dopamine depletion in the brain can cause Parkinson-like symptoms to occur in people who abuse amphetamines.
The nurse is performing an initial assessment on an alcoholic patient. Which of the following actions by the nurse would best ensure honest answers?
- A. Not asking personal questions
- B. Having a nonjudgmental attitude
- C. Including the family
- D. Promising the patient not to tell anyone
Correct Answer: B
Rationale: Maintaining a nonjudgmental attitude may reassure the patient and allow him to be more honest in his responses to the admission assessment.
A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?
- A. Cardiac problems
- B. Respiratory problems
- C. Withdrawal problems
- D. Circulatory problems
Correct Answer: C
Rationale: Diaphoresis, tremors, and hypertension are all symptoms of withdrawal from alcohol consumption. The nurse, concerned about the patient's medical condition, may not consider substance abuse until withdrawal symptoms appear.