Marcella Como38 yr-old, sexual assault victim, unknown assailant. No known past medical Hx. No known
drug allergies (NKDA). Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99% on room air. Multiple
abrasions, bruising head, chest, and inner thigh. Withdrawn, appears fearful, crying, and refusing to see
their partner. SANE nurse to make second visit today. Awaiting diagnostic labs. Taking HIV Meds for
prophylaxis. Social worker with patient this morning. Diet as tolerated.
Scenario 1
Ms. Como is first day after sexual assault. Upon entering the room, she is quiet and shows little emotion.
Scenario 2
Later in morning care, Ms. Como requests to take a shower stating she feels 'dirty'.
Scenario 3
In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. (Think
Therapeutic Communication)
Scenario 4
Marcella Como is now more talkative and shares with you that she is going to co - Correct Answers
Educational needs- increased
fall risk- normal
health change- increased
pain level- normal
psychological needs-increased
Sensorium- normal
Scene 2:
PHYSIOLOGICAL
acute discomfort-TRUE
alteration in mobility-FALSE
alteration in urinary elimination-FALSE
,readiness for enhanced immunization status-TRUE
SAFETY
fear- TRUE
grief- TRUE
potential for falls- FALSE
potential for infection- TRUE
prolonged confusion- FALSE
sleep deficit- FALSE
LOVE AND BELONGING
alteration in body image- FALSE
anxiety-TRUE
chronic sadness-TRUE
impaired family coping- TRUE
loss of power- FALSE
socially isolated- TRUE
ESTEEM
decisional conflict- FALSE
ineffectual coping-TRUE
noncompliance- FALSE
sexual assault trauma syndrome- TRUE
SELF-ACTUALIZATION
alteration in energy field- TRUE
spiritual difficulties- FALSE
Scenario 1
,-use therapeutic communication/active listening
-full assessment
-provide emotional support
-documentation
Scenario 2
-use therapeutic communication/active listening
-education patient
-provide supplies and needed instructions
-offer to assist
Scenario 3
-use therapeutic communication/active listening
-ask open-ended questions
-seek clarification
-summarize discussion
Scenario 4
-restate or paraphrase patient statements
-acknowledge patient's decision
-review plan of action
-notify social services
-document process
Scenario 5
-Review labs
-educate patient-sTD;s and pregnancy
-provide emotional support
-discuss support groups
, Linda Yuwas admitted to your unit after surgery on her left hip due to a fall. She is 2 days post-op. She is
85 years old and has a history of osteoarthritis and cataracts. PT has been getting the patient up with a
walker and she is able to take a few steps. She is aware of self and situation, but not time or day. Her
family lives out of state, but the daughter was here for the surgery, she left yesterday. The plan is to
discharge Ms. Yu back to her assisted living facility. Her daily medications at home include: Prednisone 5
mg, Furosemide 20 mg, and ASA 81 mg daily. The surgeon added oxycodone 5mg q 4-6 hours prn pain.
NKDA.
Scenario 1
Patient states her hip was hurting earlier, so she took some aspirin she had in her purse. She does not
want to take the other pain medicine and become addicted.
Scenario 2
Current vital signs are: BP: 116/82, P: 74, R:16, T:98.3, Pulse Ox: 91%. Pain level is 6/10. You enter the ro
- Correct Answers Educational needs- increased
fall risk- increased
health change- increased
neurological- normal
pain level- normal
psychological needs-normal
Scene 2:
PHYSIOLOGICAL
Acute discomfort- TRUE
Alteration in comfort- TRUE
Alteration in mobility- TRUE
SAFETY
Potential for falls -TRUE
Potential for infection- TRUE
drug allergies (NKDA). Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99% on room air. Multiple
abrasions, bruising head, chest, and inner thigh. Withdrawn, appears fearful, crying, and refusing to see
their partner. SANE nurse to make second visit today. Awaiting diagnostic labs. Taking HIV Meds for
prophylaxis. Social worker with patient this morning. Diet as tolerated.
Scenario 1
Ms. Como is first day after sexual assault. Upon entering the room, she is quiet and shows little emotion.
Scenario 2
Later in morning care, Ms. Como requests to take a shower stating she feels 'dirty'.
Scenario 3
In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. (Think
Therapeutic Communication)
Scenario 4
Marcella Como is now more talkative and shares with you that she is going to co - Correct Answers
Educational needs- increased
fall risk- normal
health change- increased
pain level- normal
psychological needs-increased
Sensorium- normal
Scene 2:
PHYSIOLOGICAL
acute discomfort-TRUE
alteration in mobility-FALSE
alteration in urinary elimination-FALSE
,readiness for enhanced immunization status-TRUE
SAFETY
fear- TRUE
grief- TRUE
potential for falls- FALSE
potential for infection- TRUE
prolonged confusion- FALSE
sleep deficit- FALSE
LOVE AND BELONGING
alteration in body image- FALSE
anxiety-TRUE
chronic sadness-TRUE
impaired family coping- TRUE
loss of power- FALSE
socially isolated- TRUE
ESTEEM
decisional conflict- FALSE
ineffectual coping-TRUE
noncompliance- FALSE
sexual assault trauma syndrome- TRUE
SELF-ACTUALIZATION
alteration in energy field- TRUE
spiritual difficulties- FALSE
Scenario 1
,-use therapeutic communication/active listening
-full assessment
-provide emotional support
-documentation
Scenario 2
-use therapeutic communication/active listening
-education patient
-provide supplies and needed instructions
-offer to assist
Scenario 3
-use therapeutic communication/active listening
-ask open-ended questions
-seek clarification
-summarize discussion
Scenario 4
-restate or paraphrase patient statements
-acknowledge patient's decision
-review plan of action
-notify social services
-document process
Scenario 5
-Review labs
-educate patient-sTD;s and pregnancy
-provide emotional support
-discuss support groups
, Linda Yuwas admitted to your unit after surgery on her left hip due to a fall. She is 2 days post-op. She is
85 years old and has a history of osteoarthritis and cataracts. PT has been getting the patient up with a
walker and she is able to take a few steps. She is aware of self and situation, but not time or day. Her
family lives out of state, but the daughter was here for the surgery, she left yesterday. The plan is to
discharge Ms. Yu back to her assisted living facility. Her daily medications at home include: Prednisone 5
mg, Furosemide 20 mg, and ASA 81 mg daily. The surgeon added oxycodone 5mg q 4-6 hours prn pain.
NKDA.
Scenario 1
Patient states her hip was hurting earlier, so she took some aspirin she had in her purse. She does not
want to take the other pain medicine and become addicted.
Scenario 2
Current vital signs are: BP: 116/82, P: 74, R:16, T:98.3, Pulse Ox: 91%. Pain level is 6/10. You enter the ro
- Correct Answers Educational needs- increased
fall risk- increased
health change- increased
neurological- normal
pain level- normal
psychological needs-normal
Scene 2:
PHYSIOLOGICAL
Acute discomfort- TRUE
Alteration in comfort- TRUE
Alteration in mobility- TRUE
SAFETY
Potential for falls -TRUE
Potential for infection- TRUE
