Case Study Mobility

Case Study: Mobility 1. 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? Answer: "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. 2. Mr. Matthew tells the nurse, "My sweetheart and I have never been apart during our 55year marriage." What action should the nurse implement to help reduce Mr. Matthew's anxiety during the admission process? Answer: Explain the room environment to Mr. and Mrs. Matthew. 3. 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? Answer: Impaired physical mobility. 4. 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? Answer: The client will sit in the chair for each meal beginning on the day of admission. 5. 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? Answer: -Teach Mr. Matthew to dorsal flex and plantar flex his feet while in the bed and chair.. -Explain enoxaparin (Lovenox) injections will be administered routinely. -Instruct him to wear sequential compression stockings 6. The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis. Which action requires the nurse to intervene? Answer: Assessing the Homan's sign in bilateral extremities. 7. The HCP has prescribed thigh-high antiembolic hose for Mr. Mathis. 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? Answer: Unilateral calf edema. 8. Which instruction should the nurse give to the unlicensed assistive personnel (UAP) for positioning Mr. Mathis' legs? Answer: Use two pillows and place one lengthwise under each calf. 9. Which nursing diagnosis best applies to Mr. Mathis' nutritional assessment? Answer: Imbalanced nutrition: less than body requirements. 10. The nurse instructs Mr. Mathis to increase his intake of which foods to prevent a decrease in bone density? Answer: Calcium rich foods. 11. Which foods should the nurse encourage? Answer: Milk, oatmeal, and an orange. 12. How should the nurse teach the UAP to position the chair to ensure a safe transfer? Answer: Position the chair at a 45 degree angle to the bed on Mr. Mathis' left side. 13. What is the priority nursing action? Answer: Gently lower Mr. Mathis to the floor. 14. How does the UAP assess for orthostatic hypotension? Answer: Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions. 15. Which action should the nurse implement? Answer: Teach Mr. Mathis to take ten deep breaths an hour while awake. 16. What is the best response by the nurse? Answer: Help the client perform the correct technique for deep breathing exercises. 17. The nurse explains to the UAP that the Braden Scale is used to measure which client parameter? Answer: Risk for pressure sores. 18. Which nursing action should be included in the plan? Answer: Reposition Mr. Mathis in bed from supine to a 30 degree side-lying position every 2 hours. 19. Before giving the initial dose, which action should the nurse take first? Answer: Ask Mr. Mathis if he is aware of any allergies to medications. 20. 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? Answer: Add buttermilk or active culture yogurt to the diet daily. 21. Which is the best approach for the nurse to prevent muscle atrophy? Answer: Teach Mr. Mathis to perform exercises such as gluteal sets and quadriceps sets five times every 2 hours while awake. 22. In planning morning care for Mr. Mathis, what action should the nurse take? Ask the UAP to assist Mr. Mathis in taking a complete bed bath. 23. Which action should the nurse implement in response to Mr. Mathis' concern? Answer: Offer to obtain a bedside commode for Mr. Mathis. 24. The nurse also develops a dietary teaching plan to reduce the risk of constipation. Which dietary selection should the nurse encourage Mr. Mathis to eat? Answer: Chicken Caesar salad with a whole wheat roll and skim milk. 25. Which is the best therapeutic approach for the nurse to engage in conversation with Mr. Mathis? Answer: "I sense a spiritual strength about you." 26. Mr. Mathis 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. Mathis' spiritual needs? Answer: Place a sign on the door to allow Mr. Mathis some quiet time in the mornings. 27. Mr. Mathis 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? Answer: Readiness for enhanced spiritual well being. RESULTS: