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    Hesi rn psychology proctored exam (mental health)

    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 indepth with the client based on this screening tool?

    Explanation & Rationale

    A. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake: Minimization and social consequences may indicate problematic drinking, but these are not the specific focus of the CAGE questionnaire. The tool is designed to identify behavioral patterns and emotional responses directly linked to potential alcohol dependence. B. Efforts to cut down, annoyance with questions, guilt, drinking as an "eye-opener": The CAGE questionnaire consists of four questions addressing Cut down, Annoyed, Guilty, and Eye-opener behaviors. Positive responses to these items suggest possible alcohol use disorder and indicate areas requiring in-depth assessment, including frequency, context, and impact of drinking. C. Consumption, liver enzyme, gastrointestinal complaints and bleeding: While these factors provide information about physical health and organ impact from alcohol use, they are not part of the CAGE screening tool itself. Laboratory and symptom assessments supplement screening but do not replace behavioral inquiry for dependence patterns. D. Cancer screening results, anger, gastritis, daily alcohol intake: Cancer screening and anger are unrelated to the CAGE tool, and gastritis alone does not directly reflect the screening criteria. Focusing on these aspects would not capture the behavioral and emotional indicators the CAGE questionnaire is designed to identify.

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