HESI Mobility Case Study
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?
“What concerns do you have about being hospitalized?”
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.
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?
Explain the room environment to Mr. and Mrs. Matthew.
This action will reduce the client’s anxiety by including the spouse and orienting them both to the room.
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?
Impaired physical mobility.
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?
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 Mr. Matthew is to achieve and sets a realistic deadline.
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?
Teach Mr. Matthew 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 thromboembolism in the legs.
Explain enoxaparin (Lovenox) injections will be administered routinely.
Lovenox is an anticoagulant administered to reduce the rick of venous thromboembolism.
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How should the nurse document the completed client teaching?
Dorsal and plantar flexion demonstrated to client and returned correctly. States he will perform 10 times an hour.
This represents a complete documentation, which includes the content taught and a statement of the client’s understanding after the teaching.
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?
Positive Homan’s sign.
Unilateral calf edema.
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the healthcare provider.
What instruction should the nurse give to the unlicensed assistive personnel (UAP) for positioning Mr. Matthew’s legs?
Use 2 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 of venous thrombosis.
Mr. Matthew is 6 feet 2 inches tall and weighs 140 pounds. The nurse calculates his Body Mass Index (BMI) as 18.The nurse continues the nutritional assessment.Mrs. Matthew tells the nurse that she cooks every day, but Mr. Matthew does not even eat his favorite foods anymore, although he does drink a lot of diet colas. Which nursing diagnosis best applies to Mr. Matthew’s nutritional assessment?
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.
Mr. Matthew 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 Mr. Matthew to increase his intake of which foods to prevent a decrease in bone density?
Calcium must be deposited in the bones to increase bone density.
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?
Milk, oatmeal, and an 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. Added benefits are vitamin A from the orange and fiber from the oatmeal and the orange.
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?
Position the chair at a 45-degree angle to the bed on Mr. Matthew’s left side.
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 into the chair.
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?
Gently lower Mr. Matthew to the floor.
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.
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?
“You probably experienced postural hypotension. Let me explain.”
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.
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?
Teach Mr. Matthew to take ten deep breaths an hour while awake.
Deep breathing can prevent atelectasis, which can lead to pneumonia.
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?
Help the client perform the correct technique for deep-breathing exercises.
Mr. Matthew 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.
As a part of the physical assessment of Mr. Matthew, the nurse utilizes the Braden Scale. The nurse explains to the UAP that the Braden Scale is used to measure which client parameter?
Risk for pressure sores.
The Braden Scale assesses many risk factors that may contribute to pressure sores. 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.
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?
Reposition Mr. Matthew in bed from supine to a 60-degree side-lying position every 2 hours.
The client should be repositioned every 2 hours. The 60-degree angle for lateral position provides comfort without placing excessive pressure on the greater trochanter.
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?
Ask Mr. Matthew 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 additional allergies after the initial admission history has been taken.
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?
Add buttermilk or active culture yogurt to the diet daily.
The friendly flora in buttermilk and active culture yogurt will help maintain or restore the normal intestinal flora, helping to reduce the incidence of diarrhea or fungal superinfection.
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?
Teach Mr. Matthew to perform exercises such as gluteal sets and quadriceps sets 5 times every 2 hours while awake.
These active isometric exercised strengthen the large muscles of the buttocks and thighs to help prevent muscle atrophy.
In planning morning care for Mr. Matthew, what action should the nurse take?
Ask the UAP to assist Mr. Matthew in taking a complete bed bath.
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 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?
Offer to obtain a bedside commode for Mr. Matthew.
A bedside commode not only allows Mr. Matthew some independence, but it also allows him to be in the correct sitting position to promote bowel action.
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?
Increase the amount of vegetables, fresh fruits, and dried fruits.
These foods are rich in fiber and help promote bowel function.
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?
“I sense a spiritual strength about you.”
This validates Mr. Matthew’s spiritual being.
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?
Place a sign on the door to allow Mr. Matthew some quiet time in the mornings.
This action alerts the staff of the need to respect Mr. Matthew’s quiet time.
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?
Readiness for enhanced spiritual well being.
Mr. Matthew indicates that he has faith and that this is an opportunity for him to grow spiritually.