HESI Mobility Flashcards
Scenario
An older adult client is treated in the emergency department for an infected wound on his right foot. The client states he was walking barefoot and stepped on something sharp that cut his foot. He treated it with topical antibiotics, but it appears red and inflamed, purulent drainage. The client is admitted to the medical-surgical unit for inpatient care treatment, and prescribed an antibiotic and pain medication.
Nursing diagnosis
The client states the pain level in his right foot is eight on a scale of 1 to 10. He says he has been favoring his foot by staying in bed the past week.
Nursing diagnosis
The client states the pain level in his right foot is eight 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 two hours is needed for moderate to severe pain. Morphine is available in parenteral dose of 2 mg/mL. How much medication should the nurse drop up for asdministration?
1.6
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.
This section should be taken first, since this is the initial dose of the new medication. It is important to verify any allergies. Client’s sometimes recall additional allergies after the initial admission history has been taken.
When the clients foot pain is controlled, which nursing diagnosis should take priority?
Impaired physical mobility.
Rationale: the clients limited activities support this nursing diagnosis. Improved mobility as a nursing priority, to prevent the mini potential complications of immobility.
Which goal is correct for the client? Diagnosis of impaired physical mobility?
The client will sit in the chair for each meal beginning on the day of admission.
Rationale: This is correctly stated goal. The client is always the subject of the goal, and the action is always miserable. The goal includes what the client is to achieve and set a realistic deadline. (SMART goal)
Prevention of Venus thrombosis
The client is reluctant to move in the bed or moved 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 has ordered an oxy injections and anti-embolic stockings. The nurse then performs a physical assessment, which reveals diminished dorsal, pus, pulses bilaterally.
Which instructions should the nurse convey to help prevent Venus rumble in the clients legs?
Teach the client to dorsal flex and plant our flex, his feet, while in the bed and chair.
Rationale: This section stimulates circulation by contracting calf muscles, which increases the Venus return of the blood to the heart. This decreases pulling of blood in the legs, which helps VTE in the legs.
Instruct the client to wear SCD stockings
Rationale: Sequential compression devices, promote to Venus blood flow, preventing VT.
Explain that an ox injections will be administered routinely.
Rationale: An ox is an anticoagulant that is administered to reduce the risk of VTE
The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene?
Assessing the Homans sign in bilateral extremities.
Rationale: Homans sign is not a reliable indicator and is potentially dangerous method because of possible clot dislodgment.
The client is wearing thigh high anti-embolic hose prescribed by healthcare provider. The nurse assesses the client like every eight hours. Which assessment finding reflex signs of possible thrombosis that should be reported to the HCP?
Unilateral calf edema
Rationale: edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the HCP.
Which instruction should the nurse give to the nursing student for positioning the clients legs when he is sitting?
Used to pillows and place one length wise under each calf.
Rationale: This method provides a slight elevation of the lower legs for discomfort, but avoids pressure behind the knees, which would adversely decrease venous return, and decrease the risk of for venous thrombosis.
Nutritional concerns
The client is 6’2” tall and weighs 140 pounds. The nurse calculates his body mass index as 18. The nurse continues the nutritional assessment. The clients 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 cola.
Which nursing diagnosis best applies to the clients nutritional assessment?
Balanced nutrition: less than body requirements.
Rationale: The trace 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.
The client indicates an interest in improving his nutrition. He says that he is worried because he has heard that bones weak when people stay in bed. He asks which food will help his bones. The nurse explains the osteoporosis can develop from a sedentary lifestyle.
The nurse instruct the client increases intake of which foods to prevent a decrease in bone density?
Calcium rich foods.
Rationale: Cassie may be deposited in the bone and increased bone density.
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.
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.
Braden scale
As a part of the physical assessment of the client, the nurse utilizes the Braden scale.
The nurse explains the student nurse that the Braden scale is used to measure which client parameter?
Risk for pressure sores.
Rationale: The brain scale, assesses, many risk factors that may contribute to pressure source. The factors that are assessed our nutrition, the ability to move, the new degree of activity, moisture on the skin, sensory perception, and friction and share. A lower score indicates a higher risk for pressure source.
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?
Reposition the client in bed from supine to a 30° sideline position every two hours.
Rationale: The client should be repositioned every two hours. The 30° angle for the lateral position provides comfort without placing excessive pressure on the greater trochanter.
Client transfer
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?
The chair at the head of the bed, facing the foot on the clients left side close to the bed.
Rationale: Placing the chair at the head of the bed, on the strongest left side, provides for a safe transfer, because it allows him to pivot easily from the bed into the armchair.
