Mobility HESI Case Study

Which is the BEST therapeutic approach for the RN to engage in conversation c̅ the pt? O "I sense a spiritual strength about you." O "I can read the book to you." O "I can pray c̅ you." O "I am a religious person too."

"I sense a spiritual strength about you." This validates the pt's spiritual being. #2 & #3 wasn't requested by the pt. #4 is inapp. to disclose.

Which educational information would the RN provide the pt to help prevent constipation? Select all that apply. O Increase physical activity as tolerated. O Drink plenty of water. O Inform the pt if he gets constipated there is a medication he can be prescribed. O Choose foods higher in fiber.

- Increase physical activity as tolerated. - Drink plenty of water. - Choose foods higher in fiber. #1 inc. peristalsis, #2 softens stool to help pass through intestine, #4 causes friction in intestine, assisting c̅ stimulating motility. #3 is not a prevention method.

Client Safety

After sitting on the floor (few min), pt is helped to standing by RN. Pt is able to walk to BR and back to bed s̅ problem. After pt is safely in bed, RN believes pt may have had an episode of orthostatic HoTN (OH).

Meet the Client

An older adult pt is treated in the ED for an infected wound on his R-foot. The pt states he was walking barefoot & stepped on something sharp that cut his foot. He treated it with topical antibiotics, but it appears red & inflamed, c̅ purulent drainage. The pt is admitted to the med-surg unit for in-pt wound care tx & prescribed an antibiotic & pain med.

Section 4 Braden Scale

As part of the focused physical assessment, the RN uses the Braden Scale.

Before giving the initial dose of pain med or antibiotic, which action should the RN take first? O Ask the client what liquid he would like to drink to swallow the pill. O Teach the client the side effects of the medication. O Ask the client if he is aware of any allergies to medications. O Instruct the client to sit upright to swallow the medication.

Ask the client if he is aware of any allergies to medications. This takes priority because it is the initial dose of a new med. #1 should still be taken, another action takes priority. #2 is important, but doesn't have immediate priority. #4 is important, but is the last step.

What is the BEST response by the RN? O Assess the pt's O2 Sat level using a pulse oximeter. O Help the pt perform the correct technique for deep breathing exercises. O Encourage the pt to practice this exercise regularly q2h. O Notify the HCP that a Rx for an incentive spirometer is needed.

Help the pt perform the correct technique for deep breathing exercises. Pt didn't show correct technique. The RN should re-teach: pt place hands above umb. & tell pt to breathe in & make hands go up. #1: doesn't correct pt's technique. #3: Correction should be done prior to repetition. #4 is unnecessary if exercise is performed correctly s̅ it.

Which nursing problem BEST applies to the pt's nutritional assessment? O Imbalanced nutrition: less than body requirements. O Imbalanced nutrition: more than body requirements. O Risk for aspiration. O Knowledge deficit: nutrition.

Imbalanced nutrition: less than body requirements. BMI > 18.5 is underweight (#2). #3 has no evid. #4 hasn't been assessed. The pt shows interest in improving nutrition. He says he is worried b/c he has heard bones weaken when people stay in bed. He asks which food will help his bones. The RN explains that osteoporosis can develop from a sedentary lifestyle.

When the client's foot pain is controlled, which nursing problem should take priority? O Risk for caregiver role strain. O Risk for social isolation. O Impaired physical mobility. O Imbalanced nutrition: more than body requirements.

Impaired physical mobility. The pt's limited activity support this. This is a nursing priority to prevent many complications. #1 exists for pt's wife, not priority. #2 can occur, but not the priority. #4 has no supporting evidence.

The pt replies, "My wife is my rock. She reads the Bible to me every morning." His eyes become teary. What should the RN do to provide for the pt's spiritual needs? O Call a chaplain for the pt to talk to about spiritual matters. O Place a sign on the door to allow pt some quiet time in the mornings. O Tell the pt that his spirituality is impressive. O Take the pt to the chapel.

Place a sign on the door to allow pt some quiet time in the mornings. This alerts staff to respect pt's quiet time. #1 hasn't been requested, but should be honored if it is. #2 This is un-solicited & non-therapeutic. #3 was not requested & may present hardship on the pt.

How should the RN teach the SN to position the chair to ensure a safe transfer? O Position the chair at the HOB on the pt's right side. O Position the chair at foot of the bed on the pt's left side. O Position the chair at foot of the bed on the pt's right side. O Position the chair at the HOB facing foot on the pt's left side close to the bed.

Position the chair at the HOB facing foot on the pt's left side close to the bed. Put chair on strong side so pt can pivot. #1, #2, #3 is not the best position for a safe transfer. The RN is in the room when pt quickly gets up OOB to go to BR. With RN assistance, the pt walks about 5ft from bed, where he stops and says, "I feel faint." He starts to fall.

The pt says he has faith that God will be with him through this challenge to regain his health. What nursing dx should be included in the plan of care? O Spiritual distress. O R/O ineffective family coping. O Readiness for enhanced spiritual well-being. O R/O impaired religiosity.

Readiness for enhanced spiritual well-being. Pt says he has faith & this is an opportunity to grow spiritually. #1 & #2: not supp-orted/no evid. #3: not a nursing dx.

Which action should the RN implement? O Teach the pt about the effects of smoking. O Encourage the pt to ambulate in the hall tid. O Teach the pt to deep breathe qh while awake to prevent atelectasis. O Ask the pt if there is a family hx of lung cancer.

Teach the pt to deep breathe qh while awake to prevent atelectasis. Atelectasis leads to pneumonia. #1 is important, but not priority. #2 is not practical c̅ weakness & foot injury. #4 will not benefit client c̅ R/O pneu.

Section 6 Respiratory Function

The RN hears the pt cough & realizes the pt is at R/O pneumonia due to lack of movement. The RN performs a focused lung assessment & auscultates fine crackles BIL in the upper lobes. The pt states that because he has smoked for 40 years, he always has a cough in the AM.

Spirituality

The RN notices a religious book in the pt's room. While talking c̅ him, he asks the RN to hand him the book.

Evaluation of Client Education

The RN shows proper technique for deep-breathing. When the pt returns the deep-breathing exercise demonstration, he raises his shoulders during inspiration.

Planning Care

The assessment scale results help the PN to identify the pt is at R/O impaired TI b/c of dec. nutrition & mobility. The PN discusses a plan of care c̅ the SN and RN team leader.

The pt is wearing thigh-high antiembolic hose ordered by HCP. The RN assesses the pt's legs q8h. Which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP? O Paresthesia. O Decreased hair growth in lower legs. O Negative for pallor. O Unilateral calf edema.

Unilateral calf edema. #1 is abnormal, but not a precursor to thrombophlebitis. #2 isn't related to thrombophlebitis. #3 is a normal finding.

Which instruction should the RN give the SN for positioning the pt's legs when he is sitting? O Use two pillows and place one lengthwise under each calf. O Let him position himself until he is comfortable. O Allow him to use the bed controls to markedly flex his knees. O Encourage him to keep his legs flat and not bend his knees.

Use two pillows and place one lengthwise under each calf. Provides slight elevation & avoids pressure behind knees, which would dec. venous return & r/o venous thrombosis. #2 needs education for best position to dec. r/o VTE. #3 dec. circulation & inc. r/o VTE. #4 abnormal body alignment, uncomfortable, marked extension of knees.

Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? Select all that apply. O Encourage the client to use the incentive spirometer 10 times an hour while awake. O Teach the client to dorsal flex and plantar flex his feet while in bed and chair. O Instruct the client to wear sequential compression stockings. O Advise the client to try not to move and cause pain in his foot wound. O Explain that enoxaparin injections will be administered routinely.

- Teach the client to dorsal flex and plantar flex his feet while in bed and chair. - Instruct the client to wear sequential compression stockings. - Explain that enoxaparin injections will be administered routinely. #2 promotes circulation by contracting calf muscles, inc. venous return. Dec. blood pooling in legs. #3 SCD promote venous flow. #5 is an anticoag. #1 prevents pneumonia, not VTE. #4 will cause VTE.

The RN is observing a SN perform a peripheral assessment on the pt. Which action requires the RN to intervene? O Palpating BIL pedal pulses. O Assessing the capillary refill in the great toe. O Assessing the Homan's sign in BIL extremities. O Apply light pressure in ankles to determine edema.

Assessing the Homan's sign in BIL extremities. Homan's sign isn't "reliable" and a potentially dangerous method b/c of possible clot dislodgment. #1 is appropriate. #2 determines blood flow; appropriate. #4 appropriate. Homan's Sign: RN- one hand on calf, one over foot; pt extends leg (knee), RN raises leg to 10 deg., passively & abruptly dorsifl. the foot while squeezing the calf. If pt has deep pain/tender, pt may have DVT.

The RN instructs the pt to increase his intake of which foods to prevent a decrease in bone density? O Any food that is high in calories. O Foods that are rich in Vitamin C. O Calcium rich foods. O High fiber foods.

Calcium rich foods. Ca must be deposited in the bone to inc. BMD. #1 is not specific to osteoporosis. #2 promotes skin integrity not OP. #4 promotes digestion, not OP. The RN is helping the pt choose foods from a reg. diet menu for tomorrow's breakfast. The pt "will try to eat more", even though he "still doesn't have much of an appetite".

The RN also develops a dietary teaching plan to reduce R/O constipation. Which dietary selection should the RN encourage the pt to eat? O Peanut butter & jelly on white bread, crackers, & a diet soda. O Chicken Caesar salad c̅ a whole wheat roll & skim milk. O Grilled cheese on rye bread, & sweet tea. O Fried chicken c̅ coleslaw & a mineral water.

Chicken Caesar salad c̅ a whole wheat roll & skim milk. Fiber-rich, promotes bowel function. #1 lacks fiber. #3 & #4 not healthiest choices.

What is the PRIORITY nursing action? O Gently lower the pt to the floor. O Check the pt's carotid pulse. O Encourage the pt to get to the bed. O Call for help in a loud voice.

Gently lower the pt to the floor. This prevents RN & pt injury. Lowering pt to the floor should be done when pt can't support one's own weight. #2 is not as important as safety. #3 isn't practical since pt can't support his own weight. #4 help can be called when pt is safe.

Which foods should the RN encourage? O Milk, oatmeal, and an orange. O Toasted bagel and tea. O Sausage biscuit and coffee. O Cinnamon roll and milk.

Milk, oatmeal, and an orange. Milk is a primary source of calcium. Milk & oatmeal provide protein. Orange provide Vitamin C & D. #2 is not nutrient-rich or have Ca. #3 is not nutrient-rich. #4 isn't the BEST option.

Section 9 Case Outcome

Over next few days, the pt's mobility improves. The S/S of infection dec. The pt reports less pain & looks forward to going home. He & the staff have met the goals estab. in the plan of care. He is discharged s̅ any complications from immobility. A home health RN will visit to supervise to pt's health for the next few weeks.

Which nursing action should be included in the plan of care? O Reposition the client in bed to a 90 degree side-lying position q2h. O Reposition the client in bed from supine to a 30 degree side-lying position q2h. O Place a hydrocolloid dressing on the client's heels. O Massage the client's reddened bony prominences c̅ lotion q2h.

Reposition the client in bed from supine to a 30 degree side-lying position q2h. 30 deg. angle provides comfort s̅ inc. press.; pt is to be repos. q2h. #1: 90 deg. angle will put press. on great. troch.: high R/O skin breakd. #3 are used on Stage 1 or 2 PI. #4 may further damage tissue. The skin WNL around red skin can be to stim. circulation.

The RN explains to the SN that the Braden Scale is used to measure which pt parameter? O Neurological status. O Risk for pressure sores. O Risk for thrombophlebitis. O Condition of the oral mucosa.

Risk for pressure sores. Assess many RF associated c̅ PIs: nutrition, func. ab., mobility, skin moisture, sens. perc., friction & shear. A dec. score->high r/o PI. #1 measured using the Glascow Coma Scale. #2 & #4: not eval. via Braden; are eval. using A scale...

How should the RN assess for OH? O Measure the pt's pulse while pt is in the sitting & standing positions. O Measure the pt's BP while pt is in the lying & standing positions. O Take the pt's pulse & BP when pt is in lying & sitting positions. O Take the pt's BP and pulse while pt is in the lying, sitting, & standing positions.

Take the pt's BP and pulse while pt is in the lying, sitting, & standing positions. OH can occur when pt has been lying/sitting for prolonged period & stands abruptly. The sys. (SBP) drops a min of 20 pts. #1 & #3: pt should be in lying, sitting, & standing positions. #2: P & BP is assessed for OH.

Which goal is correct for the client's problem of impaired physical mobility? O The client will transfer to the chair with assist of one person. O The nurse will reposition the client every hour while the client is awake. O The client will sit in the chair for each meal beginning on the day of admission. O The nurse will assist the client to ambulate in the hall by second hospital day.

The client will sit in the chair for each meal beginning on the day of admission. This is a pt goal: what pt is to achieve & sets a realistic deadline. Subject = pt; action = measurable. #1 is an incomplete goal. #2 is a nursing action, not a measurable goal. #4 is a nursing action, not a pt goal.

Section 3 Nutritional Concerns

The pt is 6'2" (1.8 m) & 140 lbs (63.6 kg). The RN calculates his BMI as 18. The RN continues nutritional assessment. The SO says she cooks every day, but the pt doesn't eat his favorite foods anymore, although he does drink a lot of diet colas.

Bowel Patterns

The pt is concerned that he may become constipated due to lack of activity & poor diet.

Section 2 Prevention of Venous Thrombosis

The pt is reluctant to move in bed or to chair. He likes spouse to place pillow beneath knee. The RN informs them that the PCP ordered enoxaparin injsterm-4 & antiembolic stockings. The RN performs a focused PA, revealing diminished dorsalis pedis pulses BIL.

Section 1 Nursing Diagnosis

The pt states the pain level in his right foot is 8/10. He says he has been favoring his foot by staying in bed the past week.

Section 5 Client Transfer

The pt tells the RN that he has a war injury causing RLE weakness. "It gives out on me sometimes." Despite injury, the RN encourages transfer from bed to chair.