Assessment and Diagnosis Flashcards

A nurse is using the SBIRT model to address substance use with a patient in a primary care setting. After the initial screening indicates risky alcohol consumption, what is the immediate next step according to this model?

Answer: Engage the patient in a brief intervention.

SBIRT stands for Screening, Brief Intervention, and Referral to Treatment. Following a positive screening, the model dictates that the healthcare provider should engage the patient in a brief, non-judgmental conversation known as a Brief Intervention. This conversation aims to provide feedback, enhance motivation for change, and collaboratively set goals. Referral to treatment is reserved for individuals identified as needing a higher level of care.

When assessing a patient for alcohol withdrawal, the nurse uses the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scale. Which of the following clusters of symptoms are all components of this assessment tool?

Answer: Nausea/vomiting, tremor, anxiety, and paroxysmal sweats

The CIWA-Ar is a 10-item scale that assesses the severity of alcohol withdrawal. The items scored include Nausea and Vomiting, Tremor, Paroxysmal Sweats, Anxiety, Agitation, Tactile Disturbances, Auditory Disturbances, Visual Disturbances, Headache/Fullness in Head, and Orientation/Clouding of Sensorium. Pupil size, bone aches, and yawning are characteristic of opioid withdrawal and assessed using the COWS scale. The other options include assessments not specific to the CIWA-Ar protocol.

According to the DSM-5, the severity of a substance use disorder is determined by the number of diagnostic criteria met within a 12-month period. A patient who meets four criteria would be diagnosed with which level of severity?

Answer: Moderate

The DSM-5 specifies the severity of a substance use disorder based on the number of criteria met: 2-3 criteria indicate a mild disorder, 4-5 criteria indicate a moderate disorder, and 6 or more criteria indicate a severe disorder. Therefore, a patient meeting four criteria falls into the moderate category.

A CARN is performing a substance use screening using the CAGE-AID questionnaire. The 'A' in the acronym CAGE-AID prompts the nurse to ask which of the following questions?

Answer: "Have people Annoyed you by criticizing your drinking or drug use?"

The CAGE-AID is an acronym for Cut down, Annoyed, Guilty, and Eye-opener. The 'A' specifically refers to whether other people have been annoyed by the individual's substance use, which can be an indicator of social problems related to their use.

A patient is being assessed for opioid withdrawal using the Clinical Opiate Withdrawal Scale (COWS). The nurse observes a resting heart rate of 115 bpm, beads of sweat on the patient's forehead, and the patient is unable to sit still for more than a few seconds. These objective findings would contribute to which components of the COWS score?

Answer: Resting Pulse Rate, Sweating, and Restlessness

The COWS is an 11-item scale that includes objective measures. A heart rate of 115 bpm would be scored under Resting Pulse Rate, visible beads of sweat fall under the Sweating category, and the inability to sit still is rated under Restlessness. The other options list different components of the COWS scale that do not match the described symptoms.

Which of the following scenarios best illustrates the DSM-5 diagnostic criterion of 'risky use' for a substance use disorder?

Answer: A patient continues to drive their commercial truck after smoking cannabis, despite company policy and safety warnings.

The 'risky use' criterion in the DSM-5 refers to recurrent substance use in situations where it is physically hazardous. Driving a vehicle while under the influence of cannabis is a clear example of this. Needing more of a substance is tolerance, unsuccessful attempts to quit relate to impaired control, and missing events due to use falls under social impairment.