Case Study 6 - Mobility

The nurse is in the room when the client quickly gets up out of bed to go to the bathroom. With the nurse's assistance, the client 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 the client to the floor. B. Check the client's carotid pulse. C. Encourage the client to get to the bed. D. Call for help in a loud voice.

A. Gently lower the client to the floor. This is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when he cannot support his own weight.

Spirituality The nurse notices a religious book in the client's room. While talking to him, he asks the nurse to hand him the religious book. Which is the best therapeutic approach for the nurse to engage in conversation with the client? 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 a religious person too

A. I sense a spiritual strength about you This validates the client's spiritual being

Which instruction should the nurse give to the nursing student for positioning the client's legs when he is sitting? A. Use two pillows and place one lengthwise under each calf. B. Let him position himself with pillows until he is comfortable C. Allow him to use the bed controls to markedly flex his knees D. Encourage him to keep his legs flat and not bend his knees.

A. Use two pillows and place one lengthwise under each calf. 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 for venous thrombosis

Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is 1mg/kg subcutaneously every 12 hours. Dose available is 80 mg per 0.8 mL

0.6

The client states that the pain level in his right foot is 8 on a scale of 1 to 10. He says he has been favoring his foot by staying in bed the past week. Client was prescribed morphine IV 0.05 mg/kg/dose now and every 2 hours as needed for moderate to severe pain. Morphine is available in parenteral dose of 2 mg/mL. How much medication should the nurse draw up for administration? (Patient weights 140 lbs on admission).

1.6 mL

Nutritional Concerns The client is 6 feet 2 inches tall and weighs 140 (63.5 kg). The nurse calculates his Body Mass Index (BMI) as 18. The nurse continues the nutritional assessment. The client's wife tells the nurse that she cooks every day, but the client does not even eat his favorite foods anymore, although he does drink a lot of diet colas. Which nursing diagnosis best applies to the client's nutritional assessment? A. Imbalanced nutrition: less than the body requirements B. Imbalanced nutrition: more than body requirements C. Risk for aspiration D. Knowledge deficit: nutrition

A. Imbalanced nutrition: less than body requirements. The choice of this diagnosis is supported by the evidence of his BMI, which is below 18.5, placing him in the underweight category, and his lack of intake of nutrients.

Bowel Patterns The client is concerned that he may become constipated due to his lack of activity and poor diet. Which educational information would the nurse provide the client to help prevent constipation? (select all that apply) A. Increase physical activity as tolerated. B. Drink plenty of water C. Inform the client if he gets constipated there is a medication he can be prescribed. D. Choose foods higher in fiber.

A. Increase physical activity as tolerated. B. Drink plenty of water D. Choose foods higher in fiber. Physical activity increases peristalsis and helps prevent constipation. Water helps soften the stool to help it pass through the intestines. Fiber causes friction in the intestines which assists with stimulating motility.

The nurse is helping the client choose foods from a regular (unrestricted) diet menu for tomorrow's breakfast. The client 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 a orange B. Toasted bagel and tea C. Sausage, biscuit, and coffee D. Cinnamon roll and milk

A. Milk, oatmeal, and a orange These are nutrient-rich choices. Milk is a primary source of calcium to prevent osteoporosis. The milk and oatmeal provide protein. The orange provides vitamin C and D

The nurse also develops a dietary teaching plan to reduce the risk of constipation. Which dietary selection should the nurse encourage the client to eat? A. Peanut butter and jelly on white bread, crackers, and a diet cola B. Chicken Caesar salad with whole wheat roll and skim milk C. Grilled cheese on rye bread and sweet tea D. Fried chicken with coleslaw and mineral water

B. Chicken Caesar salad with whole wheat roll and skim milk. These foods are rich in fiber and help promote bowel function

Evaluation of Client Education The nurse demonstrates the proper technique for deep breathing. When the client 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 ox B. Help the client perform the correct technique for deep breathing exercises C. Encourage the client to practice this exercise regularly every 2 hours D. Notify the HCP that a prescription for an incentive spirometer is needed

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

The client replies, my wife is my rock, she reads the Bible to me every morning, He becomes teary eyed. What should the nurse do to provide for his spiritual needs? A. Call a chaplain for the client to talk to about spiritual matters B. Place a sign on the door to allow the client some quiet morning time C. Tell him his spirituality is impressive D. Take him to the chapel

B. Place a sign on the door to allow the client some quiet morning time. This action alerts the staff of the need to respect his quiet time

Planning Care The assessment scale results help the nurse to identify the client is at risk for impaired skin integrity because of decreased nutrition and mobility. The nurse develops a plan of care with the student nurse. Which nursing action should be included in the plan? A. Reposition the client in a bed to a 90 degree side-lying position every 2 hours. B. Reposition the client in bed from supine to a 30 degree side-lying position every 2 hours C. Place a hydrocollid dressing on the client's heels D. Massage the client's reddened, bony prominences with lotion every 2 hours

B. Reposition the client in bed from supine to a 30 degree side-lying position every 2 hours. The client should be repositioned every 2 hours. The 30 degree angle for the lateral position provides comfort without placing excessive pressure on the greater trochanter.

Braden Scale As part of the physical assessment of the client, the nurse utilizes the Braden Scale The nurse explains to the student nurse that the Braden Scale is used to measure which client parameter. A. Neurological status B. Risk for pressure sores C. Risk for thrombophlebitis D. Condition of the oral mucosa

B. Risk for pressure sores The Braden Scale assesses many risk factors that may contribute to pressure sores. The factors that are assessed are nutrition, the ability to move, the degree of activity, moisture on the skin, sensory perception, and friction and shear. A lower score indicates a higher risk for pressure sores.

Prevention of Venous Thrombosis The client 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 informs the client and his wife that the primary care physician (PCP) has ordered enoxaparin injections and antiembolic stockings. The nurse the performs a physical assessment, which reveals diminished dorsalis pedis pulses bilaterally. Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? (Select all that apply) A. Encourage the client to use the incentive spirometer 10 times am hour while awake. B. Teach the client to dorsal flex and plantar flex his feet while in the bed and chair. C. Instruct the client to wear sequential compression stockings D. Advise the client to try not to move and cause pain in his foot wound. E. Explain that enoxaparin injections will be administered routinely.

B. Teach the client to dorsal flex and plantar flex his feet while in the bed and chair. (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 thrombosis in the legs) C. Instruct the client to wear sequential compression stockings. (Sequential compression devices (SCD's) promote venous blood flow, preventing VTE) E. Explain that enoxaparin injections will be administered routinely. (Enoxaparin is an anticoagulant that is administered to reduce the risk of VTE)

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

C. Ask the client if he is aware of any allergies to medications. 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 addition allergies after the initial admission history has been taken.

The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene? A. Palpating bilateral pedal pulses B. Assessing the capillary refill in the great toe C. Assessing the Homan's sign in bilateral extremities D. Applying light pressure in ankles to determine edema

C. Assessing the Homan's sign in bilateral extremities. Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible clot dislodgement.

The client indicates an interest in improving his nutrition. He says that he is worried because he has heard that bones weaken when people stay in bed. He asks which food will help his bones. The nurse explains that osteoporosis can develop from a sedentary lifestyle. The nurse instructs the client to increase his intake of which foods to prevent a decrease in bone density? A. Any food that is high in calories. B. Food that re rich in vitamin C C. Calcium rich foods D. High fiber foods

C. Calcium-rich foods. Calcium must be deposited in the bone to increase bone density.

When the client's foot pain is controlled 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. The client's limited activities support the nursing diagnosis. Improving mobility is a nursing priority to prevent the many potential complications of immobility.

The client says he has faith that God will be with him through this challenge to regain his health. What nursing diagnosis should be included in 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. The client indicates that he has faith and that this is an opportunity for him to grow spiritually.

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

C. Teach the client to take ten deep breaths an hour while awake. Deep breathing can help prevent atelectasis, which can lead to pneumonia

Which goal is correct for the client's diagnosis of impaired physical mobility? A. The client will transfer to the chair with assist of one person. B. The nurse will reposition the client every hour while the client is 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. 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 the client is to achieve and sets a realistic deadline.

Client Transfer The client tells the nurse that he has a war injury resulting in right leg weakness. He states, "It gives out sometimes." In spite of the weakness in his leg, the nurse encourages the client to transfer from the bed to the chair. How should the nurse teach the student nurse to position the chair to ensure a safe transfer. A. Position the chair at the head of the bed on the client's right side. B. Position the chair at the foot of the bed on the client's left side. C. Position the chair at the foot of the bed on the client's right side. D. Position the chair at the head of the bed facing the foot on the client's left side close to the bed.

D. Position the chair at the head of the bed facing the foot on the client's left side close to the bed. Placing the chair at the head of the bed on the stronger left side provides for a safe transfer because it allows him to pivot easily from the bed into the chair.

Client Safety After sitting on the floor for a few minutes, the client is helped to a standing position by the nurse. He is able to walk to the bathroom and back to bed without further problems. After the client is safely back in bed, the nurse believes the client may have had an episode orthostatic hypotension. How should the nurse assess for orthostatic hypotension? A. Measure the client's pulse while the client is in the sitting and standing position. B. Measure the client's blood pressure while the client is in the lying and standing positions C. Take the client's pulse and blood pressure when the client is in the lying and sitting positions D. Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions.

D. Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions. Orthostatic hypotension can occur when the client when 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 orthostatic hypotension.

The client is wearing thigh-high antiembolic hose prescriber by the Healthcare Provider (HCP). The nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP? A. Paresthesia B. Decreases hair growth in lower legs C. Negative for pallor D. Unilateral calf edema

D. Unilateral calf edema. Edema or swelling of one calf is a possible sign of thrombophlebitis that should be reported to the HCP