Chief Complaint/History of Present Illness

Rapid Reasoning

Chief complaint/History of Present Illness:

Past Medical History:

Your Initial VS: T: P: R: BP: O2 sats:

Your Initial Nursing Assessment: RESP: breath sounds clear with equal aeration bilat., non-labored CARDIAC: pink, warm & dry, S1S2, no edema, pulses 3+ in all extremities NEURO: alert & oriented x4, though anxious over feeling so ill GI/GU: active BS in all quads, abd. soft/non-tender, voiding without difficulty, frequency of urination, though has no burning/painful urination, urine clear/pale-clear color MISC: lips and oral mucosa tacky dry

Physician Orders:

Lab/diagnostic Results:

2. What is the underlying cause /pathophysiology of this concern? (NCLEX Client Need Category:Physiologic Adaptation)

3. Based on the data you have collected, what is your primary concern right now? (NCLEX Client Need Category:Management of Care)

4. What interventions will you initiate based on this primary concern? (start with A-B-C priorities) (NCLEX Client Need Category:Physiologic Adaptation)

5. What body system will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern? (start w/A-B-C body systems) (NCLEX Client Need Category:Physiologic Adaptation)

6. What is the worst possible complication to anticipate? (start with A-B-C priorities) (NCLEX Client Need Category:Reduction of Risk Potential)

7. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops? (NCLEX Client Need Category:Physiologic Adaptation)

8. What VS & assessment data is RELEVANT that must be recognized as clinically significant to the nurse? (NCLEX Client Need Category: Management of Care/Reduction of Risk Potential) RELEVANT VS/assessment data: Relationship to primary medical problem:

9. What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? (NCLEX Client Need Category: Management of Care/Reduction of Risk Potential) RELEVANT Diagnostic results: Relationship to primary medical problem:

10. What is the relationship between the following physician orders/meds and your patient’s primary medical problem? (NCLEX Client Need Category: Pharmacological & Parenteral Therapies) (How will mech. of action of these meds/treatments impact this patient at a pathophys. level to help resolve primary problem?) Physician orders: How it will help resolve primary problem: