Ann Rails Room 302
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
...
Ann Rails Room 302
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
You responded correctly to 4 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Status assessment reports left leg weakness; patient is unsteady, activity as tolerated.
Fall Risk Increased acuity Status assessment reports left leg weakness and pain, unsteady gait.
Health Change Increased acuity Status assessment reports abnormal weakness, unsteady gait, leg pain (5/10 scale) upon movement.
Pain Level Increased acuity Status assessment reports left leg pain (5/10 scale) upon movement.
Psychological Needs Increased acuity Status assessment reports no indication of increased psychological acuity.
Sensorium Increased acuity Status assessment reports no indication of increased sensorium acuity.
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
You correctly diagnosed 10 out of 12 options:
Physiological
Description Your Response Explanation
Acute Pain True Status assessment reports patient experiencing pain & numbness
Bleeding, Risk for False Status assessment reports no indication of incisions or wounds
Chronic Pain False Status assessment reports non-significant past medical hx
Impaired Comfort True Status assessment reports patient experiencing pain upon movement
Impaired Mobility True Status assessment reports patient experiencing gait weakness, pain, and numbness.
Nausea False Status assessment reports no indication of 'Nausea'
Safety
Description Your
Response
Explanation
Deficient Knowledge True Status assessment reports no indication of knowledge deficient
Disturbed Sensory Perception True Status assessment reports patient experiencing numbness
Fall, Risk for True Status assessment reports patient experiencing gait weakness, pain, and numbness
Grieving False Status assessment reports no indication of 'Grieving'
Infection, Risk for False Status assessment reports no indication incisions or wounds
Peripheral Neurovascular Dysfunction False Status assessment reports patient experiencing numbness and pain
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