The patient provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) query.
What interpretation should the nurse provide to the patient?
A.
One positive response indicates the patient should seek help with alcohol addiction.
B.
All responses to the CAGE Questionnaire must be positive to suggest alcohol dependence.
C.
The CAGE Questionnaire is a tool used to identify general substance abuse.
D.
At least two positive responses are strongly suggestive of alcohol dependence.
The Correct Answer and Explanation is:
The correct answer is:
D. At least two positive responses are strongly suggestive of alcohol dependence.
Explanation:
The CAGE Questionnaire is a widely used screening tool designed to identify individuals who may have alcohol dependence. It consists of four questions that assess key behaviors associated with alcohol misuse:
- 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?”
Each question aims to identify patterns or problems related to alcohol consumption. The scoring is straightforward: a “yes” answer is typically scored as one point, and a “no” as zero.
The interpretation of the CAGE Questionnaire is as follows:
- One positive response: A single positive response on the CAGE Questionnaire is not typically sufficient to confirm alcohol dependence. It suggests that there may be some concern or potential problem with alcohol, but further assessment is needed to understand the full context and severity.
- Two positive responses: When two questions are answered affirmatively, it is more suggestive of a potential alcohol problem. This level of positivity indicates that the individual may be experiencing issues related to their drinking behavior and warrants a more thorough evaluation.
- Three positive responses: Three positive responses are quite indicative of a stronger likelihood of alcohol dependence. This pattern suggests that the individual is likely struggling with alcohol-related issues and should be considered for a more comprehensive assessment and intervention.
- Four positive responses: All four positive responses strongly suggest that the individual has a significant issue with alcohol dependence, and immediate referral for specialized treatment is recommended.
The CAGE Questionnaire is specifically aimed at alcohol use, not general substance abuse, so options B and C are incorrect. Therefore, option D is the most accurate, reflecting that at least two positive responses are strongly suggestive of alcohol dependence, and further evaluation is needed to confirm the diagnosis and determine appropriate intervention.