Swift River Medical Surgical Exam
V1 Scenarios (Latest Update 2025 /
2026) Questions and Verified
Answers | Grade A | 100% Correct
Question:
Lithia Monson
Scenario 1
You arrive in room to find Ms. Monson talking to herself. Upon assessment,
you determined that she is confused to person, time, and place but is easily
directable.
Scenario 2
A special lowbed has been ordered that will lower to the ground. The bed
arrives tomorrow. You are concerned about preventing the patient from
falling.
Scenario 3
A few hours after speaking with the sitter about the patient needing complete
observation, you notice the sitter outside of the room talking on the phone.
Upon entering the room, the patient appears to be trying to get out of bed
,Scenario 4
Prior to changing shift, you enter the patient's room to complete a full
assessment, and Ms. Monson is now crying asking to for someone to take her
home!
Scenario 5
When completing the shift change neuro check, you notice the patient's left
pupil is sluggish. You also notice the patient is more difficult to orient.
Answer:
Scenario 1
-Perform neuro assess
-Reorient Patient to person, place, & time
-Assess for fall risk
-Offer nutrition/toilet
-Discuss effectiveness of sitter
Scenario 2
-Complete neuro checks as ordered
-Discuss and determine sitter availability
-Check on patient/sitter hourly
-Advise sitter to notify nurse when leaving the room
-Determine when a hospital provided sitter will be necessary
,Scenario 3
-Reassess patient
-Ensure patients is positioned in bed properly
-Discuss with sitter that patient needs continual observation
-Discuss with family sitter if there are any other family members who can help
with monitoring Lithia
-Document and contact nursing supervisor/Charge nurse
Scenario 4
-Complete full assessment, to include neuro
-Use therapeutic communication/active listening
-Attempt to orient to person, place, and time
-Offer nutrition and/ or toileting
-Ensure bed is in lowest position, and rails are in place
Scenario 5
-Notify HCP of neuro findings
-Notify charge nurse of patient's deteriorating condition
-Begin q15 minute neuro checks
-Have patient remain in bed, head elevated 30 degrees
-Ensure IV is patent
, Question:
Lithia Monson
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
Answer:
Physiological-
Bleeding, Risk for: True
Decreased Cardiac/perfusion: False
Imbalanced Nutrition: True
Nausea: False
Self-Care Deficit: True
Shock, Risk for: False
Safety-
Acute Confusion: True
Fall, risk for: True
Peripheral Neurovascular Dysfunction: False
V1 Scenarios (Latest Update 2025 /
2026) Questions and Verified
Answers | Grade A | 100% Correct
Question:
Lithia Monson
Scenario 1
You arrive in room to find Ms. Monson talking to herself. Upon assessment,
you determined that she is confused to person, time, and place but is easily
directable.
Scenario 2
A special lowbed has been ordered that will lower to the ground. The bed
arrives tomorrow. You are concerned about preventing the patient from
falling.
Scenario 3
A few hours after speaking with the sitter about the patient needing complete
observation, you notice the sitter outside of the room talking on the phone.
Upon entering the room, the patient appears to be trying to get out of bed
,Scenario 4
Prior to changing shift, you enter the patient's room to complete a full
assessment, and Ms. Monson is now crying asking to for someone to take her
home!
Scenario 5
When completing the shift change neuro check, you notice the patient's left
pupil is sluggish. You also notice the patient is more difficult to orient.
Answer:
Scenario 1
-Perform neuro assess
-Reorient Patient to person, place, & time
-Assess for fall risk
-Offer nutrition/toilet
-Discuss effectiveness of sitter
Scenario 2
-Complete neuro checks as ordered
-Discuss and determine sitter availability
-Check on patient/sitter hourly
-Advise sitter to notify nurse when leaving the room
-Determine when a hospital provided sitter will be necessary
,Scenario 3
-Reassess patient
-Ensure patients is positioned in bed properly
-Discuss with sitter that patient needs continual observation
-Discuss with family sitter if there are any other family members who can help
with monitoring Lithia
-Document and contact nursing supervisor/Charge nurse
Scenario 4
-Complete full assessment, to include neuro
-Use therapeutic communication/active listening
-Attempt to orient to person, place, and time
-Offer nutrition and/ or toileting
-Ensure bed is in lowest position, and rails are in place
Scenario 5
-Notify HCP of neuro findings
-Notify charge nurse of patient's deteriorating condition
-Begin q15 minute neuro checks
-Have patient remain in bed, head elevated 30 degrees
-Ensure IV is patent
, Question:
Lithia Monson
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
Answer:
Physiological-
Bleeding, Risk for: True
Decreased Cardiac/perfusion: False
Imbalanced Nutrition: True
Nausea: False
Self-Care Deficit: True
Shock, Risk for: False
Safety-
Acute Confusion: True
Fall, risk for: True
Peripheral Neurovascular Dysfunction: False
