SWIFT RIVER SIMULATION - ADULT MEDICAL
SURGICAL EXAM QUESTIONS WITH
VERIFIED ANSWERS
Ann Rails 24 years old, admitted for back pain. The injury, according to her report, occurred as a
result of a domestic dispute in which she was pushed into a kitchen counter. She has no other
significant medical history. No known allergies (NKA). Her last vital signs are blood pressure
124/82, temperature 98.2, pulse 84, respiration rate 22, SpO2 96% on room air. She states she
has had pain and numbness in her legs for one week. There is abnormal left leg weakness, gait
unsteady, 5/10 on numeric pain scale. She is receiving Lortab 2 tabs every 6 hours, which she
states relieves her pain. Her neuro assessment is within expected parameters, except for the leg
pain upon movement. Activity as tolerated with assistance; we have asked her to call for
assistance when getting out of bed. She is on a regular diet, but she has had very little intake
since she has been here. Her children have visited, but we have not seen her - Correct Answers -
Maslow's Hierarchy of Needs - High Priority
Airway, Breathing, Circulation - Low Priority
Safety and Risk Reduction - High Priority
Urgent vs Non-urgent - Low Priority
Chronic vs Acute/Stable vs Unstable - Low Priority
Initial Nursing Assessment
0745: The nurse reviews the information received in report.
Which of the following concerns should the nurse address while providing client care? (Select all
that apply.)
Safety: Injury Prevention
Physiological: Mobility
Physiological: Pain
Physiological: Sensory
Physiological: Nutrition
Physiological: Elimination
, Safety: Self-harm
Physiological: Thermoregulation - Correct Answers -Safety: Injury Prevention
Physiological:5Mobility5
Physiological:5Pain5
Physiological:5Sensory
08005The5nurse5enters5the5client's5room5and5introduces5themself.5The5nurse5notices5the5client5is5
crying.5The5nurse5questions5the5client5about5why5they5are5crying.5The5client5states,5"Everything5in
5my5life5is5just5so5messed5up,5and5my5back5is5hurting5again."
Which5of5the5following5actions5should5the5nurse5prioritize?5(Select5all5that5apply.)
Ask5the5client5to5rate5their5pain5on5a505to5105pain5scale5
Check5the5client's5MAR5to5determine5if5pain5medication5can5be5administered5
Offer5the5client5comfort5through5therapeutic5communication5
Continue5with5a5complete5head-to-toe5assessment5of5the5client5
Ask5the5client5why5she5has5not5been5eating5or5drinking5since5admission5
Re-position5the5client5for5comfort5
Reinforce5to5the5client5to5call5for5assistance5before5getting5out5of5bed5-5Correct5Answers5-
Ask5the5client5to5rate5their5pain5on5a505to5105pain5scale5
Check5the5client's5MAR5to5determine5if5pain5medication5can5be5administered5
Offer5the5client5comfort5through5therapeutic5communication5
Re-position5the5client5for5comfort5
Reinforce5to5the5client5to5call5for5assistance5before5getting5out5of5bed
08455Following5administration5of5the5pain5medication5at50815,5the5nurse5enters5the5client's5room
5to5check5their5pain5level5and5perform5an5assessment.5The5client5has5a5flat5affect5but5is5no5longer5
crying.5The5client's5report5of5pain5at508005was585on5a5pain5scale5of505to510,5now5they5rate5their5pai
n5at53.5The5nurse5obtains5the5client's5vital5signs,5which5are5Temp598.9F,5BP5128/82,5P577,5RR518,5Sp
SURGICAL EXAM QUESTIONS WITH
VERIFIED ANSWERS
Ann Rails 24 years old, admitted for back pain. The injury, according to her report, occurred as a
result of a domestic dispute in which she was pushed into a kitchen counter. She has no other
significant medical history. No known allergies (NKA). Her last vital signs are blood pressure
124/82, temperature 98.2, pulse 84, respiration rate 22, SpO2 96% on room air. She states she
has had pain and numbness in her legs for one week. There is abnormal left leg weakness, gait
unsteady, 5/10 on numeric pain scale. She is receiving Lortab 2 tabs every 6 hours, which she
states relieves her pain. Her neuro assessment is within expected parameters, except for the leg
pain upon movement. Activity as tolerated with assistance; we have asked her to call for
assistance when getting out of bed. She is on a regular diet, but she has had very little intake
since she has been here. Her children have visited, but we have not seen her - Correct Answers -
Maslow's Hierarchy of Needs - High Priority
Airway, Breathing, Circulation - Low Priority
Safety and Risk Reduction - High Priority
Urgent vs Non-urgent - Low Priority
Chronic vs Acute/Stable vs Unstable - Low Priority
Initial Nursing Assessment
0745: The nurse reviews the information received in report.
Which of the following concerns should the nurse address while providing client care? (Select all
that apply.)
Safety: Injury Prevention
Physiological: Mobility
Physiological: Pain
Physiological: Sensory
Physiological: Nutrition
Physiological: Elimination
, Safety: Self-harm
Physiological: Thermoregulation - Correct Answers -Safety: Injury Prevention
Physiological:5Mobility5
Physiological:5Pain5
Physiological:5Sensory
08005The5nurse5enters5the5client's5room5and5introduces5themself.5The5nurse5notices5the5client5is5
crying.5The5nurse5questions5the5client5about5why5they5are5crying.5The5client5states,5"Everything5in
5my5life5is5just5so5messed5up,5and5my5back5is5hurting5again."
Which5of5the5following5actions5should5the5nurse5prioritize?5(Select5all5that5apply.)
Ask5the5client5to5rate5their5pain5on5a505to5105pain5scale5
Check5the5client's5MAR5to5determine5if5pain5medication5can5be5administered5
Offer5the5client5comfort5through5therapeutic5communication5
Continue5with5a5complete5head-to-toe5assessment5of5the5client5
Ask5the5client5why5she5has5not5been5eating5or5drinking5since5admission5
Re-position5the5client5for5comfort5
Reinforce5to5the5client5to5call5for5assistance5before5getting5out5of5bed5-5Correct5Answers5-
Ask5the5client5to5rate5their5pain5on5a505to5105pain5scale5
Check5the5client's5MAR5to5determine5if5pain5medication5can5be5administered5
Offer5the5client5comfort5through5therapeutic5communication5
Re-position5the5client5for5comfort5
Reinforce5to5the5client5to5call5for5assistance5before5getting5out5of5bed
08455Following5administration5of5the5pain5medication5at50815,5the5nurse5enters5the5client's5room
5to5check5their5pain5level5and5perform5an5assessment.5The5client5has5a5flat5affect5but5is5no5longer5
crying.5The5client's5report5of5pain5at508005was585on5a5pain5scale5of505to510,5now5they5rate5their5pai
n5at53.5The5nurse5obtains5the5client's5vital5signs,5which5are5Temp598.9F,5BP5128/82,5P577,5RR518,5Sp
