1. Nurse T admit Assess respiratory status
Ms. S. Priority ac-
tion for T to take?
2. Nurse T assess Hamilton-A
Ms. S. Which as-
sessment scales
is appropriate?
3. Nurse T com- Lorazepam
pletes the Hamil-
ton-A assess-
ment of Ms. S and
determines her
score to be 26.
Which appropri-
ate action for the
nurse to take?
4. Nurse T prepar- S (Situation) = Ms. Simpson is a 22-year-old
ing to call African-American female admitted to the inpatient mental
provider. List the health unit for anxiety. She is restless and fidgety, has poor
findings. concentration, and has been experiencing chest pain and
shortness of breath.
B (Background) = She has a history of generalized anxiety
disorder and has previously taken paroxetine 20 mg PO
daily, but has not been taking it for approximately 2 weeks.
A (Assessment)= Her vital signs from report at 0745 were:
heart rate 115, blood pressure 148/76, respirations 32,
oxygen saturation 96% on room air, and temperature 37.0
C (98.6 F). Her score on the Hamilton A scale is 26, and
she has been unable to focus on answering questions due
to her severe level of anxiety. She continues to pace, wring
her hands, and rock when sitting.
R (Recommendation) = I am calling to request a prescrip-
tion for lorazepam.
5. Nurse T is calcu- 0.5
lating the dose of
1/3