Mobility Case Study

The nurse notices a religious book in the client's room. While talking with 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?

"I sense a spiritual strength about you."

Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first?

Ask the client if he is aware of any allergies to medications.

The client is 6 feet 2 inches tall and weighs 140 lbs (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?

Imbalanced nutrition: less than body requirements.

When the client's foot pain is controlled, which nursing diagnosis should take priority ?

Impaired physical mobility.

The client 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 the client's spiritual needs?

Place a sign on the door to allow the client some quiet time in the mornings.

The client tells the nurse that he has 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 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?

Position the chair at the head of the bed facing the foot on the client's left side close to the bed.

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 the plan of care?

Readiness for enhanced spiritual well being.

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?

Reposition the client in bed from supine to a 30 degree side-lying position every 2 hours.

The nurse hears the client cough and realizes the client is at risk for pneumonia due to lack of movement. The nurse performs a lung assessment and auscultates fine crackles bilaterally in the upper lobes. The client states that because he has smoked for 40 years, he always has a cough in the morning. Which action should the nurse implement?

Teach the client to take ten deep breaths an hour while awake.

The client is wearing thigh-high antiembolic hose prescribed 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?

Unilateral calf edema.

Which instruction should the nurse give to the nursing student for positioning the client's legs when he is sitting?

Use two pillows and place one lengthwise under each calf.

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. One, some, or all options may be correct.)

-Increase physical activity as tolerated. -Drink plenty water. -Choose foods higher in fiber.

Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? (Select all that apply. One, some, or all options may be correct.)

-Teach the client to dorsal flex and plantar flex his feet while in the bed and chair. -Instruct the client to wear sequential compression stockings. -Explain that enoxaparin injections will be administered routinely.

Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is 1mg/kg subcutaneously every 12 hours and the client weighs 140 lbs. Dose available is 80mg per 0.8 mL. How many milliliters will the nurse administer to the client? (Enter the numeric value only. If rounding is necessary, round to the nearest tenth.)

0.6 mL

Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate to severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should the nurse draw up for administration? (Patient weighs 140 lbs on admission). (Enter the numerical value only. If rounding is necessary, round to the nearest tenth

1.6 mL

The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene?

Assessing the Homan's sign in bilateral extremities.

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?

Calcium rich foods.

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?

Chicken Caesar salad with a whole wheat roll and skim milk.

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?

Gently lower the client to the floor.

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?

Help the client perform the correct technique for deep breathing exercises.

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?

Milk, oatmeal, and an orange.

As a 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?

Risk for pressure sores.

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?

Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions.

Which goal is correct for the client's diagnosis of impaired physical mobility?

The client will sit in the chair for each meal beginning on the day of admission.