HESI: Mobility

The nurse notices a Bible in Mr. Matthew's room. While talking with him, the nurse senses a feeling of serenity about him. How should the nurse speak to Mr. Matthews? A. "I sense a spiritual strength about you." B. "I can read the Bible to you." C. "I can pray with you." D. "I am Christian."

A. "I sense a spiritual strength about you." Rationale: This validates Mr. Matthews spiritual being.

During the course of antibiotic therapy, the amount of normal body flora is reduced in the gastrointestinal tract. Which client instruction is important to prevent the complications due to reduced body flora? A. Add buttermilk or active culture yogurt to the diet daily. B. The occurrence of diarrhea indicates an allergy to the drug. C. Take the drug within 15 minutes of the scheduled time. D. If a sour mouth develops, stop taking the medication.

A. Add buttermilk or active culture yogurt to the diet daily. Rationale: A friendly flora in buttermilk and active culture yogurt will help maintain or restore normal intestinal flora, helping reduce the incidence of diarrhea or fungal superinfection. "D" is not right correct because a sore mouth can indicate an oral fungal infection, which is a complication related to a reduction in body flora. Candidiasis should be reported to the healthcare provider. However, it is important that the antibiotic be continued for the full prescribed course.

Mr. Matthew tells the nurse, "My sweetheart and I have never been apart during our 55-year marriage." What action should the nurse implement to help reduce Mr. Matthew's anxiety during the admission process? A. Explain the room environment to Mr. and Mrs. Matthew. B. Ask Mrs. Matthew if she would like to rest in the waiting room. C. Ask Mr. Matthew if he would like a prescription for an antianxiety medication. D. Reassure Mr. and Mrs. Matthew that everything will be okay.

A. Explain the room environment to Mr. and Mrs. Matthew. Rationale: This action will reduce the client's anxiety by including the spouse and orientating them both to the room.

The nurse is in the room when Mr. Matthew quickly gets up out of bed to go to the bathroom. With the nurse's assistance, he walks about 5 feet from the bed, where he stops and states, "I feel faint." He then starts to fall. What is the priority nursing action? A. Gently lower Mr. Matthew to the floor. B. Check Mr. Matthew's carotid pulse. C. Encourage Mr. Matthew to get to the bed. D. Call for help in a loud voice.

A. Gently lower Mr. Matthew to the floor. Rationale: This is the priority nursing action to prevent injury to the client and the nurse, lowering Mr. Matthew to the floor should be done when he cannot support his own weight.

Mr. Matthew says he has faith that God will be with him through this challenge to regain his health. What nursing diagnosis should be included in the plan of care? A. Spiritual distress. B. Risk for ineffective family coping. C. Readiness for enhanced spiritual well being. D. Risk for impaired religiosity.

C. Readiness for enhanced spiritual well being. Rationale: Mr. Matthew indicates that he has faith and that is an opportunity for him to grow spiritually.

Mr. Matthew states that because he has smoked for 40 years, he always has a cough in the morning. The nurse performs a lung assessment and auscultates fine crackles bilaterally in the upper lobes. The nurse realizes Mr. Matthew is at risk for pneumonia. Which action should the nurse implement? A. Teach Mr. Matthew's about the effects of smoking B. Encourage Mr. Matthew to ambulate in the hall three times a day. C. Teach Mr. Matthew to take ten deep breaths an hour while awake. D. Ask Mr. Matthew if there is a family history of lung cancer.

C. Teach Mr. Matthew to take ten deep breaths an hour while awake. Rationale: Deep breathing can help prevent atelectasis, which can lead to pneumonia. "A" is not right because knowledge of the effects of smoking is important, but is not the nurse's most immediate concern. "D" is not right because obtaining a family history of lung cancer is not an action that will benefit a client at risk for pneumonia.

The nurse is helping Mr. Matthew choose foods from a regular (unrestricted) diet menu for tomorrow's breakfast. Mr. Matthew says he will try to eat more, even though he still doesn't have much of an appetite. Which foods should the nurse encourage? A. Milk, oatmeal, and an orange. B. Toasted white bread and tea. C. Biscuit, jelly, and coffee. D. Sweet roll and milk.

A. Milk, oatmeal, and an orange. Rationale: These are nutrient rich choices, milk is a primary source of calcium to prevent osteoporosis; milk and oatmeal provide protein and an orange provides vitamin C; added benefits are vitamin A from the orange and fiber form the oatmeal and the orange.

Because Mr. Matthew stayed in bed for a week prior to hospitalization and has had only limited ambulation while in the hospital, the nurse is concerned about muscle atrophy. What should the nurse implement to prevent muscle atrophy? A. Teach Mr. Matthew to perform exercises such as gluteal sets and quadriceps sets 5 times every 2 hours while awake. B. Teach Mr. Matthew to perform active range of motion exercises of his arms and legs twice a day. C. Instruct the UAPs to perform passive range of motion exercises twice a day. D. Instruct the UAPs to reposition Mr. Matthew in bed every 2 hours while awake.

A. Teach Mr. Matthew to perform exercises such as gluteal sets and quadriceps sets 5 times every 2 hours while awake. Rationale: These active isometric exercises strengthen the larger muscles of the buttocks and thighs to help prevent muscle atrophy. "B" is not correct because while these exercises can help prevent contractures, they do not help prevent muscle atrophy. "C" is not correct because passive exercises by the nursing staff can help prevent contractures, but they do not help prevent muscle atrophy. "D" is not correct because this action is beneficial in preventing pressure sores but not muscle atrophy.

What instruction should the nurse give to the unlicensed assistive personnel (UAP) for positioning Mr. Matthew's legs? A. Use 2 pillows and place one lengthwise under each calf. B. Let him position himself with pillows until he is comfortable. C. Allow him to use bed controls to markedly flex his knees. D. Encourage him to keep his legs flat and not bend his knees.

A. Use 2 pillows and place one lengthwise under each calf. Rationale: This method provides a slight elevation of the lower legs for comfort but avoids pressure behind the knees, which would adversely decrease venous return and decrease the risk of thrombus formation. "B" is not right because although comfort is important, the client needs education on the best position to decrease risk of thrombus formation. "C" is not right because marked flexion of the knees decreases circulation in the legs and increases the risk for thrombus formation.

Mr. Matthew tells the nurse that he has never been hospitalized. He appears anxious and frequently turns to his wife for reassurance. What is the best response by the nurse? A. "Is there anything you would like to ask your healthcare provider?" B. "What concerns do you have about being hospitalized." C. "We give good care to all our clients in the hospital." D. "Your healthcare provider the chosen the best hospital in the city."

B. "What concerns do you have about being hospitalized?" Rationale: This response utilizes principles of therapeutic communication. It is an open-ended question designed to allow Mr. Matthew to verbalize any concerns about hospitalization that might be contributing to his anxiety.

The nurse demonstrates the proper technique for deep-breathing. When Mr. Matthew returns the deep-breathing exercise demonstration, he raises his shoulders during inspiration. What is the best response by the nurse? A. Assess the client's oxygen saturation level using a pulse oximeter B. Help the client perform the correct technique for deep-breathing exercises. C. Encourage the client to practice this exercise every 2 hours. D. Notify the healthcare provider that a prescription for a incentive spirometer is needed.

B. Help the client perform the correct technique for deep-breathing exercises. Rationale: Mr. Matthew's has not demonstrated correct technique, the nurse should help him place his hands on his abdomen above the belly button and instruct him to try and breathe in and make his hands go up. This method is generally effective in teaching the client deep-breathing by using the diaphragm (abdominal breathing) to expand the lungs.

The nurse also develops a dietary teaching plan to reduce the risk of constipation. Which instruction should the nurse provide to Mr. Matthew concerning his diet? A. Decrease the number of colas from four a day to one a day. B. Increase the amount of vegetables, fresh fruits, and dried fruits. C. Add hard cheese, saltine crackers, and peanut butter to the diet. D. Substitute coffee and hot teas for the colas he drinks in the a.m. and p.m.

B. Increase the amount of vegetables, fresh fruits, and dried fruits. Rationale: These foods are rich in fiber and help promote bowel function.

Mr. Matthew is concerned that he may become constipated due to his lack of activity and poor diet. Which action should the nurse implement in response to Mr. Matthew's concern? A. Plan to obtain a prescription for a Fleet enema. B. Offer to obtain a bedside commode for Mr. Matthew. C. Encourage the use of a bedpan after each meal. D. Teach Mr. Matthew the importance of ambulation.

B. Offer to obtain a bedside commode for Mr. Matthew. Rationale: It allows Mr. Matthew some independence and allows him to be in the correct sitting position for bowel action. "A" is not correct because a hypotonic Fleet enema is used to treat constipation, not prevent it. "C" is not correct because while eating does stimulate peristalsis and the gastroclonic impulse, the use of a bedpan is awkward and it will not prevent constipation.

Mr. Matthew replies, "My wife is my rock. She reads the Bible to me every morning." His eyes become teary. What should the nurse do to provide for Mr. Matthew's spiritual needs? A. Call a chaplin for Mr. Matthew to with about spiritual matters. B. Place a sign on the door to allow Mr. Matthew some quiet time in the mornings. C. Tell Mr. Matthew that his spirituality is impressive. D. Take Mr. Matthew to the chapel.

B. Place a sign on the door to allow Mr. Matthew some quiet time in the mornings. Rationale: This action alerts the staff of need to respect Mr. Matthews quite time.

The assessment scale results help the nurse to recognize Mr. Matthew is at risk for impaired skin integrity because of decreased nutrition and mobility. The nurse develops a plan of care with the UAP. Which nursing action should be included in the plan? A. Reposition Mr. Matthew in bed to a 90-degree side-lying position every 2 hours. B. Reposition Mr. Matthew in bed from supine to a 60-degree side-lying position every 2 hours. C. Remind Mrs. Matthew's that her husband should be repositioned every 2 hours. D. Massage Mr. Matthew's reddened, bony prominences with lotion every 2 hours.

B. Reposition Mr. Matthew in bed from supine to a 60-degree side-lying position every 2 hours. Rationale: The client should be repositioned every 2 hours. The 60-degree angle for the lateral position provides comfort without placing excessive pressure on the greater trochanter. "C" is not correct because it is not the wife's responsibility. "D" is not correct because redness of the skin over a bony prominences may indicate that the skin is damaged, massaging the reddened area may further damage the tissue; the normal skin around the reddened skin can be massaged to stimulate circulation.

Mr. Matthew is reluctant to move in the bed or move to the chair. He likes his wife to place a pillow under his knee. The nurse performs a physical assessment, which reveals diminished dorsalis pedis pulses bilaterally. Which instruction(s) should the nurse convey to help prevent venous thromboembolism (VTE) in Mr. Matthew's legs? (Select all that apply) A. Encourage Mr. Matthew to cough and breathe deeply 10 times an hour. B. Teach Mr. Matthew to dorsal flew and planter flex his feet while in the bed and chair. C. Instruct Mr. Matthew to change positions every 2 hours in the bed or chair. D. Advise Mr. Matthew to eat well-balanced meals and between-meals snacks. E. Explain enoxaparin (Lovenox) injections will be administered routinely.

B. Teach Mr. Matthew to dorsal flex and plantar flex his feet while in the bed and chair. Rationale: This action stimulates circulation by contracting calf muscles, which increases the venous return of blood to the heart. This decreases pooling of blood in the legs, which helps prevent venous thromboembolism in the legs. E. Explain enoxaparin (Lovenox) injections will be administered routinely. Rationale: Lovenox is an anticoagulant administered to reduce the risk of venous thromboembolism. "A" is not right because this action helps prevent pneumonia, not venous return. "C" is not right because this action is more specific for preventing skin breakdown and pneumonia than venous thromboembolism formation in the legs. "D" is not right because it will not prevent thromboembolism.

The healthcare provider prescribed an oral antibiotic for Mr. Matthew on admission to the hospital to treat the ulcer on his right foot. Before giving the initial dose, which action should the nurse take first? A. Ask Mr. Matthew what liquid he would like to drink to swallow the pill. B. Teach Mr. and Mrs. Matthew's about the side effects of the medication. C. Ask Mr. Matthew if he is aware of any allergies to medications. D. Instruct Mr. Matthew to sit upright to swallow the medication.

C. Ask Mr. Matthew if he is aware of any allergies to medications. Rationale: This action should be taken first since this is the initial dose of a new medication. It is important to verify any allergies. Clients sometimes recall additional allergies after the initial admission history has been taken.

6. How should the nurse document the completed client teaching? A. Nurse demonstrated foot exercises to client to be done 10 times an hour in room. Tolerated teaching well. B. Nurse explained foot exercises to client and wife. C. Dorsal and plantar flexion demonstrated to client and returned correctly. States he will perform 10 times an hour. D. Dorsal and plantar flexion taught to client and wife. Both stated their appreciation for the attention.

C. Dorsal and plantar flexion demonstrated to client and returned correctly. States he will perform 10 times an hour. Rationale: This represents a complete documentation, which includes the content taught and a statement of the client's understanding after the teaching.

Mr. Matthew states the pain level in his right foot is 8 on a scale of 1-10. He says he has been favoring his foot by staying in bed the past week. In planning his care, which nursing diagnosis should take priority? A. Risk for caregiver role strain. B. Risk for social isolation. C. Impaired physical mobility. D. Imbalanced nutrition: more than body requirements.

C. Impaired physical mobility. Rationale: Mr. Matthew's limited activities support this nursing diagnosis. Improving mobility is a nursing priority to prevent the many potential complications.

In developing a plan of care, the nurse consults with Mr. Matthew to identify a short-term goal. Which goal is correct for Mr. Matthew's diagnosis for impaired mobility? A. The client will demonstrate better mobility by time of discharge. B. The nurse will reposition the client every 2 hours while awake. C. The client will sit in the chair for each meal beginning on the day of admission. D. The nurse will assist the client to ambulate in the hall by the second hospital day.

C. The client will sit in the chair for each meal beginning on the day of admission. Rationale: This is a correctly stated goal. The client is always the subject of the goal, and the action is always measurable. This goal includes what Mr. Matthew is to achieve and sets a realistic deadline. "A" is wrong because it is an uncompleted goal. "B" and "C" are wrong because they are nursing actions and not a client goal.

After sitting on the floor for a few minutes, Mr. Matthew is helped to a standing position by the nurse and the UAP. He is able to walk to the bathroom and back to bed without further problems. After Mr. Matthew is safely back in bed, he asks the nurse, "What caused me to feel faint?" How should the nurse respond to Mr. Matthews? A. "That is a good question. Sometimes these things just happen." B. "That is a good question. We need to ask the healthcare provider to explain it to you." C. "You are deficient of energy from the lack of nutrition for many days." D. "You probably experienced postural hypotension. Let me explain."

D. "You probably experienced postural hypotension. Let me explain." Rationale: Postural hypotension can occur when the client has been lying or sitting for a prolonged period and quickly rises to an erect position. The systolic blood pressure must drop a minimum of 20 points to be considered postural hypotension.

22. In planning morning care for Mr. Matthew, what action should the nurse take? A. Assign the UAP to get Mr. Matthew a complete bed bath, focusing on the right foot. B. Instruct the UAP to give Mr. Matthew a partial bed bath, making sure the right foot is cleansed. C. Encourage Mrs. Matthew to give Mr. Matthew a complete bed bath. D. Ask the UAP to assist Mr. Matthew in taking a complete bed bath.

D. Ask the UAP to assist Mr. Matthew in taking a complete bed bath. Rationale: The UAP should only assist by helping to bathe Mr. Matthew's back and feet. It is best if Mr. Matthew can do the majority of the bath on his own. This will provide him with a sense of independence, as well as the exercise to help prevent muscle atrophy.

Mr. Matthew tells the nurse that he had a war injury resulting in right leg weakness. He states, "It gives out on me sometimes." In spite of the weakness in his leg, the nurse encourages Mr. Matthew to transfer from the bed to the chair. How should the nurse teach the unlicensed assistive personnel (UAP) to position the chair to ensure a safe transfer? A. Position the chair at a 90 degree angle to the bed on Mr. Matthew's right side. B. Position the chair at a 90 degree angle to the bed on Mr. Matthew's left side. C. Position the chair at a 45 degree angle to the bed on Mr. Matthew's right side. D. Position the chair at a 45-degree angle to the bed on Mr. Matthew's left side.

D. Position the chair at a 45-degree angle to the bed on Mr. Matthew's left side. Rationale: Placing the chair at a 45 degree angle on Mr. Matthew's stronger left side provides for a safe transfer because it allows him to pivot easily from the bed to the chair.

The healthcare provider has prescribed thigh-high antiembolic hose (TEDs) for Mr. Matthew. The nurse assesses the client's legs every 8 hours. Which assessment finding(s) reflects signs of possible thrombophlebitis that should be reported to the healthcare provider? A. Negative for paresthesia. B. Bounding pedal pulse. C. Negative for pallor. D. Unilateral calf edema.

D. Unilateral calf edema. Rationale: Edema or swelling of one calf is a possible sign of thrombophlebitis that should be reported to the healthcare provider. "A" is not right because paresthesia is an abnormal sensation, such as tingling or numbness, it is not a warning sign of thrombus formation. "B" is not right because it is not related to thrombus formation. "C" is not right because lack of paleness is a normal finding.