which client information indicates the need for the nurse to use the cage questionnaire during the admission interview
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Nursing Elites

HESI LPN

Mental Health HESI 2023

1. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct answer: C

Rationale: The correct answer is C. Describing oneself as a social drinker who consumes alcoholic beverages daily raises concerns about potential alcohol abuse issues. The CAGE questionnaire is a tool used to screen for alcohol use disorder. Choice A is incorrect as memory difficulties post-traumatic brain injury do not directly indicate a need for the CAGE questionnaire. Choice B is incorrect as the use of antidepressants, while important to note, does not specifically warrant the use of the CAGE questionnaire. Choice D is incorrect as a recent sexual assault, while significant, does not directly relate to the need for alcohol abuse screening using the CAGE questionnaire.

2. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

Correct answer: D

Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.

3. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?

Correct answer: D

Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.

4. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

5. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed.

Correct answer: D

Rationale: The correct order of addressing the 12-step program typically begins with admitting powerlessness over the addiction and recognizing the unmanageability of one's life (Choice C). Following this, individuals move towards acknowledging their wrongs and sharing them with others (Choice A), then being ready to work on changing their character defects (Choice B), and finally, integrating the 12-step principles into their daily lives and helping others (Choice D). Choices A, B, and C are important steps in the program but come after admitting powerlessness and unmanageability, which is why Choice D is the correct answer.

Similar Questions

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A 30-year-old sales manager tells the nurse, 'I am thinking about a job change. I don't feel like I am living up to my potential.' Which of Maslow's developmental stages is the sales manager attempting to achieve?
A client with major depressive disorder is prescribed an SSRI. After one week, the client reports feeling no improvement in mood. What is the best response by the RN?
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During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?

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