A nurse performing an assessment interview for a patient with a substance abuse disorder decides to use a standardized rating scale. Which scales are appropriate? (Select all that apply.)

A) Addiction Severity Index (ASI)
B) Brief Drug Abuse Screen Test (B-DAST)
C) Abnormal Involuntary Movement Scale (AIMS)
D) Cognitive Capacity Screening Examination (CCSE)
E) Recovery Attitude and Treatment Evaluator (RAATE)

A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. Based on these findings, what two signs is the patient exhibiting?

A) Tanner and Hegar
B) Hegar and Goodell
C) Chadwick and Hegar
D) Goodell and Chadwick

Which assessment findings lead the nurse to inform the family that the patient's death is imminent?

A) The patient's pupils are fixed and dilated bilaterally.
B) The patient is lethargic,drifting in and out of consciousness.
C) The patient's breathing is harsh and congested with periods of apnea.
D) The patient had only 40 mL in the urinary catheter bag for the last 8 hours.
E) The patient's temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled.

The nurse is working in an outpatient clinic in her community.Late in the afternoon,three clients come in with suspected pediculosis.Which of the following assessments will the nurse perform?

A) Integumentary assessment for head lice
B) Oral assessment for bad breath and caries
C) Musculoskeletal assessment for spine alignment
D) Lower extremity assessment for athlete's foot

When assessing a patient's pain, the nurse records that the patient has visceral pain. Which condition would the patient have stated in order for the nurse document visceral pain?

A) A hip fracture
B) Cholecystitis
C) Second-degree burns
D) Pain after a leg amputation

A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI) ?

A) Drapes the urinary drainage tubing with no dependent loops
B) Washes the drainage tube toward the meatus with soap and water
C) Places the urinary drainage bag gently on the floor below the patient
D) Allows the spigot to touch the receptacle when emptying the drainage bag