The nurse is using the CAGE questionnaires as a screening tool for a

client who is seeking help because his wife said he had a drinking

problem. What information should the nurse explore indepth with the

client based on this screening tool?

A. Consumption, liver enzyme, gastrointestinal complains and

bleeding.

B. Minimizes drinking frequently misses family events, guilt about

drinking, and amount of daily intake.

C. Cancer screening results, anger, gastritis, daily alcohol intake.

D. Efforts to cut down, annoyance with questions, guilt, drinking as an

“Eye-opener”.

(Cutting down, annoyance, guilt and eye-opener drinking are

represented with the acronym of CAGE)

A client who is admitted with a closed head injury after a gall has a

blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which

intervention during the first 6 hours following admission should the

nurse identify as the priority?

A. Place in a side-lying position with head of bed elevated.

B. Administer disulfram (Atabuse ) immediately

C. Give lorezapam (Ativan)PRN for signs of withdrawal.

D. Provide thiamine and folate supplements as prescribed.