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?
Explanation & Rationale
Choice A reason: Cancer screening, anger, gastritis, and daily intake are not part of the CAGE questionnaire, which focuses on cut down, annoyance, guilt, and eye-opener. These factors are unrelated to the validated screening tool, making this incorrect for exploring alcohol use based on CAGE criteria.Choice B reason: The CAGE questionnaire screens for alcohol dependence by assessing efforts to cut down, annoyance when questioned, guilt about drinking, and using alcohol as an eye-opener. These directly identify problematic drinking patterns, aligning with addiction screening evidence, making this the correct choice for in-depth exploration.Choice C reason: Consumption, liver enzymes, and gastrointestinal issues are relevant to alcohol use but not part of the CAGE questionnaire. CAGE focuses on behavioral indicators like guilt and annoyance. This choice includes non-CAGE criteria, making it incorrect for the screening tool’s specific focus.Choice D reason: Minimizing drinking and missing family events are not CAGE criteria, though guilt is. The full CAGE framework (cut down, annoyance, guilt, eye-opener) better captures alcohol dependence. This choice is incomplete and includes non-CAGE items, making it incorrect for CAGE-based exploration.