Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?
A.
Reports difficulties with short term memory since a traumatic brain injury.
B.
Medical history includes that the client was recently sexually assaulted.
C.
Describes self as a social drinker who drinks alcoholic beverages daily.
D.
Client’s medication history includes the frequent use of antidepressants.
The Correct Answer and Explanation is:
The correct answer is C. Describes self as a social drinker who drinks alcoholic beverages daily.
Explanation:
The CAGE questionnaire is a screening tool used to identify potential alcohol use problems. The acronym CAGE stands for four questions designed to assess alcohol consumption and its impact on an individual’s life. The four questions are:
- Cut down: Have you ever felt you should cut down on your drinking?
- Annoyed: Have people annoyed you by criticizing your drinking?
- Guilty: Have you ever felt bad or guilty about your drinking?
- Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
A positive response to two or more of these questions suggests the need for a more detailed assessment of alcohol use and its potential impact on the client’s health.
In this case, the client describes themselves as a “social drinker who drinks alcoholic beverages daily.” This description suggests regular alcohol consumption, which can be a red flag for problematic drinking. Daily consumption of alcohol, even if described as “social,” might indicate a level of alcohol use that could be problematic or indicative of dependence, particularly if the consumption is high or leading to any adverse effects.
The other options do not directly relate to alcohol use:
- A (Reports difficulties with short-term memory since a traumatic brain injury) addresses cognitive issues likely unrelated to alcohol use.
- B (Medical history includes that the client was recently sexually assaulted) pertains to trauma and its psychological impacts, which are not directly related to alcohol use.
- D (Client’s medication history includes the frequent use of antidepressants) suggests treatment for mental health issues but does not inherently indicate problematic alcohol use.
Using the CAGE questionnaire for a client who drinks daily can help determine if their drinking patterns are a sign of a more serious issue, thereby guiding appropriate interventions or referrals for further assessment and support.