HESI Mobility Case Study Guide Exam Questions with Correct Answers

HESI Mobility Case Study Guide Exam Questions with Correct Answers Explain enoxaparin (Lovenox) injections will be administered routinely. Lovenox is an anticoagulant administered to reduce the rick of venous thromboembolism. How should the nurse document the completed client teaching? - Answer-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? - Answer-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? - Answer-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? - Answer-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? - Answer-Calcium-rich foods. Calcium must be deposited in the bones to increase bone density.