Swift River Simulation - Adult Medical Surgical - Ann Rails
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 - answer 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 - answer Safety: Injury Prevention
Physiological: Mobility Physiological: Pain Physiological: Sensory
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 - answer 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 - answer Safety: Injury Prevention
Physiological: Mobility Physiological: Pain Physiological: Sensory
