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Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known
allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and
cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV
maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with
minimal assistance. Family at beside. Dr. Sangerstien - - Educational Needs
Increased
Fall Risk Increased
Health Change Increased
Pain Level Increased
Psychological Needs Normal
Sensorium Normal
Ann Rails, 38 years old, c/o back pain, non-significant past medical history. No known
allergies (NKA). Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain and
numbness in legs for one week. Abnormal left leg weakness, gait unsteady, 5/10 on
numeric pain scale. Neuro WNL, except leg pain upon movement. Activity as tolerated with
assistance. D/C plan- decrease pain and restore normal gait. Regular diet. Dr. Suculo -
- Educational Needs Increased
Fall Risk Increased
Health Change Increased
Pain Level Increased
Psychological Needs Normal
Sensorium Normal
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,Swift River Med Surg Clinical Exam Test Questions with
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Virginia Smith, 57-year-old who has elected to have a total mastectomy based on
consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all
or most of axillary lymph nodes and chest muscles intact. She is also to receive radiation,
chemotherapy, and hormone therapy post operatively. She is with her physician. She is also
investigating bone marrow transplantation. She has arrived in pre-op and about to have
surgery this morning. Her husband and two grown children are also with her as she is
prepared with gown and head cap awaiting transport to the operating room. She has IV
access and has received a small dose of Valium to reduce apprehension. Temperature is
98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. - - Educational Needs Increased
Health Change Increased
LOC Normal
Pain Level Normal
Psychological Needs Normal
Safety Increased
Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from
nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74,
P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self, speech
clear, poor historian, did not recognize son today which is new for her; Neuro assessment
and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased
fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep-
Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand.
Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist
with bath. Dr. Altace - - Educational Needs Increased
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, Swift River Med Surg Clinical Exam Test Questions with
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Fall Risk Increased
Health Change Increased
Pain Level Increased
Psychological Needs Increased
Sensorium Increased
Linda Pittmon, a 74 -year old female patient who is a noncompliant diabetic, and frequently
stays at the local homeless shelter. She has been admitted to the floor with complaints of
numbness in her right foot and ankle. Mrs. Pittmon states she has had numbness for years
but "now I can't feel it at all, and my toes don't look the right color.". - - Educational
Needs Increased
Fall Risk Increased
Health Change Increased
Neurological Increased
Pain Level Normal
Psychological Needs Normal
Sarah Kathryn Horton, 25 -year old graduate student was brought to the emergency room
via ambulance after being shot on the local college campus. Sarah was admitted to Med-
Surg at 2am. She has two through and through gun-shot wounds. One to her right thigh and
one to her right shoulder. She has a 20- gauge peripheral IV to left forearm with 75 mL/hr. of
0.9% saline infusing. Vital signs are stable at this time, alert and oriented x3, reports pain
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