Scenarios

• Linda Park, 58

  Morning Check-In

  Post-op day 2, stable. She just wants someone to acknowledge her. Say hello, ask one question, and you're done.

• Walter Simmons, 78

  Explaining DNR — Patient Has Questions

  A 76-year-old man with COPD signed a DNR during his last admission and now tells you he is not sure what he agreed to. He asks whether it means the team will stop his antibiotics and his oxygen. He is alert and oriented with no documented cognitive impairment. His daughter is not present. He wants to understand it before the physician rounds this afternoon.

• Daughter of Rose Carey (deceased), 68

  Bereavement Support — After Patient Death

  Your patient died three days ago on your unit. Her daughter gave the unit written permission to call. You were the nurse who cared for her the last four nights. You have the phone in your hand and the daughter answers on the second ring.

• Husband of Gloria Tran, 68

  Anticipatory Grief — Teaching the Family

  Your patient has weeks to live. Her husband of 41 years stops you in the hallway, says she seems a little stronger today, and asks when she can restart physical therapy. She is sleeping 20 hours a day, has stopped eating, and the team has met with him twice this week. Prepare him for what is coming without stripping away his hope.

• Son of Eleanor Marsh, 72

  Family Asks If Morphine Is Speeding Up Death

  Your patient is comfortable on a morphine infusion in her final hours. Her son stops you in the hallway and asks directly whether the morphine is killing her. She received a dose 20 minutes ago for respiratory distress and is now breathing quietly at 12 breaths per minute. The family has been at the bedside all day.

• Family of Robert Kwan, 84

  Final Hours — Comfort Care for the Family

  An 82-year-old man is in his final hours. His breathing is irregular with long pauses, his knees and feet are mottled, and he has been unresponsive for six hours. His wife, son, and two grandchildren are at the bedside and no one knows what to do. Someone asks whether he can still hear them. There are no further treatments to give.

• Arthur Klein, 82

  Advance Directive Conflict — Family Demands Full Code

  An 82-year-old man was admitted after a massive stroke. A notarized advance directive on the chart specifies DNR/DNI and names his wife as healthcare proxy. He is unresponsive and cannot communicate. His son arrives from out of state, has not seen the directive, and is loudly demanding that everything be done. His wife is crying and says she does not want to fight with her son.

• Clarence Davis, 88

  Final Hours at the Bedside

  An 88-year-old man on home hospice is actively dying. His breathing rises and falls with pauses up to 20 seconds, his hands and knees are mottled, and he has not responded to voice for eight hours. There is audible upper airway secretion rattle. His wife and two daughters are at the bedside. One daughter asks whether he is suffocating.

• Family of Tyler Grant (patient is brain-dead, age 24), 52

  Supporting a Family Approached About Organ Donation

  A 24-year-old man sustained severe head trauma four days ago. Two physician examinations have documented no brain or brainstem function; the ventilator is maintaining his body. His parents were told of the findings two hours ago by the attending. The organ procurement coordinator will lead the donation conversation and asks you to be present because the family trusts you. His mother keeps asking you whether he might still wake up.

• Noah Garcia, 7

  Calming an Agitated Pediatric Patient

  A seven-year-old boy needs an IV started for antibiotics. He is crying, kicking, and has pulled his arm away twice. He tells you that last time it took four tries. His parents stand at the foot of the bed looking helpless. He is otherwise stable: HR 118, RR 24, temp 38.4, fully alert. Child life is available and topical anesthetic is stocked on the unit.

• Kevin Walsh, 69

  Difficult Family at the Bedside

  Your patient's daughter has been at the bedside since 0600. She has questioned every decision, timed your medication rounds, and just told you his 0900 pain medication was 25 minutes late. She has now asked to speak to your supervisor. Her father is comfortable, pain 3 out of 10, and stable. She has not eaten or left the room all day.

• Son of Patricia Dunn (caller), 52

  HIPAA — Family Calls for Patient Information

  Your patient is a 52-year-old woman admitted with pneumonia. Her adult son calls the unit asking for an update and says he is her next of kin. There is no release of information on file and she has not authorized anyone. She is awake and able to speak for herself. The son becomes irritated and repeats that he is family.

• Fatima Al-Rashid, 39

  Interpreter Services — Language Barrier

  A 39-year-old Arabic-speaking woman is scheduled for a diagnostic procedure this afternoon and consent has not been obtained. Her adult son is at the bedside and offers to interpret. No family member is a certified interpreter. A telephone interpreter line and a video interpreter cart are available on the unit. The provider explained the procedure in English and left the consent form at the bedside.

• Mark Huang, 58

  Near-Miss Insulin Error — Reporting and Disclosure

  You drew up 10 units of regular insulin instead of the ordered 1 unit for a 58-year-old patient whose glucose is 142. You caught it at the bedside during the second check, before any was given. Nothing reached the patient. The vial and syringe are still in your hand. The patient saw you stop and asked what happened. Your primary nurse is in the next room.

• Gerald Hutchins, 71

  Patient Refuses a Medication

  A 71-year-old man refuses his atorvastatin. He tells you he never wanted to take it, that it makes his legs ache, and that no one has ever listened to him about it. He is alert and oriented and is not refusing anything else. His provider has not been told about the muscle aches.

• Howard Miller, 43

  Redirecting an Inappropriate Patient

  Your patient has made three sexually suggestive comments during your shift, the most recent while you were changing his dressing. He is alert and oriented with no cognitive impairment or disinhibiting diagnosis documented. You still need to finish the dressing change, give his 1400 medications, and ambulate him. You are working alone in the room.

• Norma Chen, 57

  Patient Asks What You Think They Should Do

  A 58-year-old woman with newly diagnosed breast cancer has been offered two treatment options and must choose by Friday. She turns to you and asks what you would do if it were you. She has read the printed materials, met with the surgeon, and says she trusts you more than anyone else on the team.

• Agnes Morrow, 84

  The Eleventh Call Light

  Your patient has used the call light eleven times since breakfast. None of the requests were urgent: water, the blinds, the TV remote, a blanket, the time. She is 84, admitted after a fall, and her daughter went home last night for the first time in a week. It is now 1400, you have three other patients, and the aide has started rolling her eyes.

• Josh Connelly (mother's boyfriend, speaking for Grace, age 4), 31

  Bruises and a Story That Doesn't Match

  A 4-year-old girl is brought in after a reported fall from a couch. You find bruises on both upper arms in the shape of finger marks, a yellow-green bruise on her left cheek, and a fresh purple bruise on her lower back. Her X-ray shows a healing posterior rib fracture that no one has mentioned. Her mother says she is clumsy and falls constantly. The child does not cry during the exam and does not look at her mother.

• Layla Hassan, 27

  Command Hallucinations — De-escalation and Safety

  A 27-year-old woman is brought to the emergency department by her family after three days without sleep. Her speech is disorganized and hard to follow. She tells you a voice is telling her to hurt her sister, and that last night at home she said she might. She is pacing, has not eaten in two days, and will not sit down. Paramedic vitals: BP 138/86, HR 110, temp 37.1. She has no psychiatric history and no known substance use.

• Helen Thornton, 87

  Dementia with Acute Behavioral Crisis

  An 87-year-old woman with moderate Alzheimer's disease is on post-operative night one after hip fracture repair. She is trying to climb over the bed rail, does not recognize staff, and is shouting for her mother. Her daughter reports she is normally calm, oriented to place, and sleeps through the night. Vitals: BP 158/88, HR 104, temp 37.9, SpO2 92 percent on room air. She has received 4 mg IV morphine in six hours, has not voided in nine hours, and it is 0230 with the overhead light on.

• Thomas Gallagher, 65

  Post-Op Cardiac Surgery — Day One Assessment

  Twelve hours after a triple coronary artery bypass graft, a 66-year-old man is awake and extubated. He rates his incisional pain 7 out of 10. Vitals: BP 118/68, HR 88 sinus rhythm, SpO2 95 percent on 3 L, temp 37.4. Two mediastinal chest tubes have drained 40 mL of serosanguineous fluid in the last hour. The sternal dressing is dry and intact. Orders include IV morphine 2 mg every 2 hours PRN. His wife and son have been waiting six hours.

• Gerald Peterson, 68

  ICU Admission — Systematic Assessment

  You are receiving a new ICU admission from the ED: a 62-year-old man intubated one hour ago for hypoxemic respiratory failure. Handoff reports ETT 7.5 secured at 22 cm at the lip, ventilator on assist-control volume, rate 16, tidal volume 450, FiO2 60 percent, PEEP 8. Current vitals: BP 104/62, HR 98, SpO2 94 percent, temp 38.1. He is sedated on propofol. His wife is in the waiting room and has not been updated.

• Margaret Cho, 71

  ICU Delirium — Sedation Wean

  A 74-year-old woman was weaned from sedation and extubated this morning after two days on the ventilator. She is awake but tells you she is at her sister's house and needs to catch a bus, and she is pulling at her IV line and telemetry leads. Vitals: BP 138/76, HR 96, SpO2 95 percent on 2 L, temp 37.2. Her last documented CAM-ICU was negative yesterday. It is 0300 and the room lights are on.

• Ruth Blackwell, 74

  Ventilated Patient — Comfort and Family Update

  Day two on the ventilator for a 70-year-old woman with pneumonia. She is lightly sedated and cannot report pain. You observe brow furrowing, orbital tightening, clenched fists, and resistance to the ventilator. Vitals: BP 152/88, HR 108, respiratory rate 24 over a set rate of 14. Orders include fentanyl 25 mcg IV every hour PRN. Her daughter has been at the bedside since admission, has not gone home, and asks you whether her mother is in pain.

• Jasmine Reid, 19

  ED Abdominal Pain — Initial Assessment

  A 19-year-old woman comes to the ED with right lower quadrant pain that began 12 hours ago. She has a midterm tomorrow and was hoping this would be nothing. Triage vitals: temp 37.9, HR 104, BP 118/72, RR 18. She has vomited twice, has not eaten since last night, and rates the pain 7 out of 10. Her last menstrual period was five weeks ago. Her mother is in the waiting room and she asks you not to discuss anything in front of her.

• Derek Wallace, 34

  ED Alcohol Intoxication — Safety and De-escalation

  A 34-year-old man was brought in by police after being found unresponsive in a parking lot. He is awake now, angry, and demanding to leave. His blood alcohol level is 0.28. Vitals: BP 148/90, HR 106, RR 16, SpO2 96 percent, temp 36.6, glucose 92. He has a 3 cm abrasion above his right eyebrow and cannot tell you how he got it. He is unsteady on his feet and swears at you when you ask him to sit down.

• Steven Park, 52

  ED Chest Pain — Initial Triage Assessment

  A 52-year-old man walks up to your triage window with chest pain that started 45 minutes ago. He drove himself and parked in the wrong lot. His color is gray and he is diaphoretic. He describes pressure across his chest radiating to his left jaw, 8 out of 10, with nausea. Vitals: BP 92/58, HR 112, RR 22, SpO2 94 percent. He smokes, takes no medications, and says his father died of a heart attack at 55.

• Olivia Park (father David Park, 38, speaking), 8

  Pediatric Anaphylaxis

  An eight-year-old girl ate a cookie at a birthday party 10 minutes ago and is now in your ED. She has hives across her trunk, audible stridor, and a persistent cough. Respiratory rate 34, HR 142, BP 84/50, SpO2 91 percent. She weighs 25 kg. She has no prior reactions and no known allergies. Standing orders permit epinephrine 0.01 mg/kg IM, maximum 0.3 mg, repeated in 5 to 15 minutes as needed. Diphenhydramine and albuterol are also available.

• Sofia Martinez (speaking for daughter Lucia, age 3), 28

  Pediatric Fever — ED Assessment with Anxious Parent

  A three-year-old girl has a temperature of 103.8 F. Her mother has been up two nights and is convinced it is meningitis. The child is playful, eating a popsicle, and pulling at your stethoscope. Vitals: HR 138, RR 26, SpO2 99 percent, capillary refill under 2 seconds. Her neck is supple, there is no rash, immunizations are current, she is drinking well and has had three wet diapers today. Her mother asks whether she needs a spinal tap.

• Robert Hammond, 67

  Acute Stroke — Door to CT

  A 68-year-old man arrives at triage with left-sided weakness and slurred speech that began 45 minutes ago; he drove himself in. He cannot lift his left arm against gravity, his left face droops, and his speech is slurred but understandable. Vitals: BP 178/96, HR 88 irregular, SpO2 96 percent, glucose 112. He takes apixaban for atrial fibrillation and took his morning dose. His daughter arrives and asks what is happening.

• Jordan Taylor, 15

  School Nurse — Asthma Rescue Inhaler Education

  A tenth-grade boy is sent to your school health office after coughing and wheezing during gym. He is comfortable now: respiratory rate 18, no audible wheeze, speaking in full sentences, peak flow 85 percent of his personal best. He has albuterol in his backpack. Asked to show you how he uses it, he puts it in his mouth and presses twice quickly while breathing in through his nose. He has no spacer and no asthma action plan on file.

• Rachel Novak, 31

  Immunization Clinic — Vaccine Hesitancy

  A mother brings her four-year-old daughter for kindergarten immunizations. The child is due for MMR, DTaP, and varicella. The mother says she has been watching videos online and is worried the MMR causes autism. She is polite but firm: she will accept the other two, not the MMR. The child is well, temperature 36.8, no allergies, no immunocompromise in the household.

• Jennifer Walsh, 45

  Screening for Opioid Misuse — Screen, Educate, Refer

  A 44-year-old woman is in for a hypertension follow-up; her BP today is 138/84. During intake screening she tells you she has taken her mother's oxycodone for low back pain three times in the past two weeks and does not think it is a problem. She has no prescription of her own and no history of substance use treatment. She rates the back pain 6 out of 10 most days.

• Danielle Foster, 42

  Home Visit — Suicidal Ideation

  You are in a 68-year-old woman's living room for a scheduled wound care visit. She screened positive on the depression questionnaire. On follow-up she tells you she thinks about killing herself every day, has decided she would use her late husband's handgun, and knows it is in the bedroom closet. She has told no one. She lives alone. She asks you not to tell her daughter.

• Herbert Williams, 72

  Home Visit — Uncontrolled Diabetes

  First home visit after discharge for a hyperosmolar hyperglycemic event. He is 67 and lives with his wife. His discharge summary lists an A1C of 11.2. He shows you his logbook: this morning's fasting glucose was 268. He insists his diet is fine and says he stopped the metformin because it upset his stomach. His test strips expired last year.

• Danielle Ferris, 30

  Why Am I Bleeding So Much? — Two Hours Postpartum

  Two hours after an uncomplicated vaginal delivery. Her pad is saturated and she just changed it for the second time this hour. Fundus is firm at the umbilicus on your check. No one explained what to expect.

• Maya Chen, 26

  First-Time Mom, Contractions Close Together, Scared to Come In 'Too Early'

  39 weeks, first pregnancy. She's been having contractions about 4 to 5 minutes apart for the last two hours, increasingly painful. She's worried you'll tell her to go home and that she's wasting everyone's time.

• Priya Nair, 33

  Sudden Late Decelerations During Active Labor

  She's 6 cm, epidural working well, comfortable and chatting with her husband. The monitor just started showing a pattern of late decelerations with the last three contractions that wasn't there twenty minutes ago.

• Olivia Marsh, 34

  Declining the Recommended Induction

  She's 41 weeks. Her provider recommended induction today and explained the risks of waiting. She's read about it herself and wants to decline for now, asking for a non-stress test and to go home to wait a bit longer instead.

• Hannah Delgado, 29

  Grieving a Loss at 22 Weeks

  Ultrasound just confirmed no fetal heartbeat at 22 weeks. She will need to labor and deliver. Neither of them has said much since being told. There are decisions ahead about seeing and holding the baby, naming, photos, and what happens afterward, and no one has been able to talk to them yet.

All scenarios are available in the app.