HESI Case Study: Mobility
What is the priority nursing action?
A) Gently lower the client to the floor. Rationale: 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.
Which nursing diagnosis best applies to the client's nutritional assessment?
A) Imbalanced nutrition: less than body requirements. Rationale: 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.
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.)
A) Increase physical activity as tolerated. B) Drink plenty water. D) Choose foods higher in fiber. Rationale: 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 intestine which assists with stimulating motility.
Which foods should the nurse encourage?
A) Milk, oatmeal, and an orange. Rationale: 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.
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. 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 for venous thrombosis.
When the client's foot pain is controlled, which nursing diagnosis should take priority?
C) Impaired physical mobility. Rationale: The client's limited activities support this 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 the plan of care?
C) Readiness for enhanced spiritual well-being. Rationale: The client indicates that he has faith and that this is an opportunity for him to grow spiritually.
Which action should the nurse implement?
C) Teach the client to take ten deep breaths an hour while awake. Rationale: Deep breathing can help prevent atelectasis, which can lead to pneumonia.
Which goal is correct for the client's diagnosis of impaired physical mobility?
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 the client is to achieve and sets a realistic deadline.
How should the nurse teach the student nurse to position the chair to ensure a safe transfer?
D) Position the chair at the head of the bed facing the foot on the client's left side close to the bed. Rationale: 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.
How should the nurse assess for orthostatic hypotension?
D) Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions. Rationale: Orthostatic 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 orthostatic hypotension.
The client is wearing thigh-high Anti embolic 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?
D) Unilateral calf edema. Rationale: Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the HCP.
Which is the best therapeutic approach for the nurse to engage in conversation with the client?
A) "I sense a spiritual strength about you." Rationale: This validates the client's spiritual being.
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.)
140 lb / 2.2 lb = 63 kg 63kg x 1 mg = 63 mg 63 mg/ 80 mg = 0.7875 0.7875 x 0.8 ml = 0.63 ml 0.63 ml (Round) = 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).
140 lb /2.2 lb = 63 kg 63 kg x 0.05 mg = 3.15 mg 3.15 mg / 2 ml = 1.575 ml 1.575 ml (Round) = 1.6 ml
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?
B) Chicken Caesar salad with a whole wheat roll and skim milk. Rationale: These foods are rich in fiber and help promote bowel function.
What is the best response by the nurse?
B) Help the client perform the correct technique for deep breathing exercises. Rationale: 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 generally effective in teaching the client deep breathing by 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." His eyes become teary. What should the nurse do to provide for the client's spiritual needs?
B) Place a sign on the door to allow the client some quiet time in the mornings. Rationale: This action alerts the staff of the need to respect the client's quiet time.
Which nursing action should be included in the plan?
B) Reposition the client in bed from supine to a 30-degree side-lying position every 2 hours. Rationale: 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.
The nurse explains to the student nurse that the Braden Scale is used to measure which client parameter?
B) Risk for pressure sores. Rationale: 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.
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.)
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. E) Explain that enoxaparin injections will be administered routinely. Rationale: This action stimulates circulation by contracting calf muscles, which increases the venous return of blood to the heart. These decreases pooling of blood in the legs, which helps VTE in the legs. Sequential compression devices (SCD) promote venous blood flow, preventing VTE. 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?
C) Ask the client 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.
The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene?
C) Assessing the Homan's sign in bilateral extremities. Rationale: Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible clot dislodgment.
The nurse instructs the client to increase his intake of which foods to prevent a decrease in bone density?
C) Calcium rich foods. Rationale: Calcium must be deposited in the bone to increase bone density.