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1. Ann Rails: Scenario Ann Rails is a 24-year
old who came to the
emer- gency
department early
this morning with
reports of back pain.
The client's partner
stated that the client
"fell from a step
ladder." Multiple
bruises were noted on
the client's right
forearm, back & face in
varying stages of heal-
ing. Current vital
signs are:
Temperature: 37°C
(98.6°F)
Pulse: 94/min
Respirations: 20/min
BP: 126/86 mm Hg
SpO2: 98%
The client re-
ceived
hydrocodone/ac-
etaminophen 2 hr ago
for pain of 6 on a scale
of 0 to
10. On reassessment,
the client rated the pain
as a 2 on a scale of 0 to
10. The client's partner
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, Swift River Simulation 2.0 Assignment (4) Answered Correctly
2025!!!
remains at the
bedside.
2. (Ann Rails) Based on the initial assessment Safety: Injury Prevention
findings & client reports, which of the
following concerns should the nurse address Physiological: Comfort
when providing care?
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, Swift River Simulation 2.0 Assignment (4) Answered Correctly
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Physiological: Mobility
Physiological: Pain
3. (Ann Rails) Following the client assessment, Review the client's MAR
the nurse plans to address the client's pain &
report of muscle cramping in lower back. Assist the client in
chang- ing positions
Suggest the client watch
television
Otter to perform back
massage
4. (Ann Rails) According to the MAR, Ensure the client's envi-
hydrocodone/ac- etaminophen was last ronment is safe.
administered at 0500 & is prn every 3 hours.
The nurse returns to the client's room & Use therapeutic
communi-
administers another dose of
hydrocodone/aceta-
minophen as prescribed. The nurse proceeds to assist cation to
further assess the
the client in changing positions to a more comfortable client.
, turns on the television for distraction per the
positionto Case
referral Make a
client's request, & offers to perform a back
massage on the client to relieve the muscle Management.
cramping, which the client has declined. The
Document client's
client's partner has stepped out of the room
state- ments using
to go to the cafeteria, & the client
their exact
, "I didn't really fall from a step ladder. My partner
states
& I were arguing, & they pushed me backward into the wording.
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