Case Study 6-Mobility Exam Questions
and Answers
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.
Prevention of Venous Thrombosis
The client 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 informs the client and his wife that the primary care
physician (PCP) has ordered enoxaparin injections and antiembolic stockings. The
nurse the performs a physical assessment, which reveals diminished dorsalis pedis
pulses bilaterally.
Which instructions should the nurse convey to help prevent venous thromboembolism
(VTE) in the client's legs?
(Select all that apply)
A. Encourage the client to use the incentive spirometer 10 times am hour while awake.
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
D. Advise the client to try not to move and cause pain in his foot wound.
E. Explain that enoxaparin injections will be administered routinely. - Answer-B. Teach
the client 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 thrombosis in the legs)
C. Instruct the client to wear sequential compression stockings.
(Sequential compression devices (SCD's) promote venous blood flow, preventing VTE)
E. Explain that enoxaparin injections will be administered routinely.
(Enoxaparin 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?
A. Palpating bilateral pedal pulses
B. Assessing the capillary refill in the great toe
C. Assessing the Homan's sign in bilateral extremities
D. Applying light pressure in ankles to determine edema - Answer-C. Assessing the
Homan's sign in bilateral extremities.
, Homan's sign is "not a reliable indicator" and is a potentially dangerous method
because of possible clot dislodgement.
The client is wearing thigh-high antiembolic hose prescriber 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?
A. Paresthesia
B. Decreases hair growth in lower legs
C. Negative for pallor
D. Unilateral calf edema - Answer-D. Unilateral calf edema.
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 client's
legs when he is sitting?
A. Use two pillows and place one lengthwise under each calf.
B. Let him position himself with pillows until he is comfortable
C. Allow him to use the bed controls to markedly flex his knees
D. Encourage him to keep his legs flat and not bend his knees. - Answer-A. Use two
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
for venous thrombosis
Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is
1mg/kg subcutaneously every 12 hours. Dose available is 80 mg per 0.8 mL - Answer-
0.6
Nutritional Concerns
The client is 6 feet 2 inches tall and weighs 140 (63.5 kg). The nurse calculates his
Body Mass Index (BMI) as 18. The nurse continues the nutritional assessment. The
client's 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 colas.
Which nursing diagnosis best applies to the client's nutritional assessment?
A. Imbalanced nutrition: less than the body requirements
B. Imbalanced nutrition: more than body requirements
C. Risk for aspiration
D. Knowledge deficit: nutrition - Answer-A. Imbalanced nutrition: less than body
requirements.
and Answers
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.
Prevention of Venous Thrombosis
The client 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 informs the client and his wife that the primary care
physician (PCP) has ordered enoxaparin injections and antiembolic stockings. The
nurse the performs a physical assessment, which reveals diminished dorsalis pedis
pulses bilaterally.
Which instructions should the nurse convey to help prevent venous thromboembolism
(VTE) in the client's legs?
(Select all that apply)
A. Encourage the client to use the incentive spirometer 10 times am hour while awake.
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
D. Advise the client to try not to move and cause pain in his foot wound.
E. Explain that enoxaparin injections will be administered routinely. - Answer-B. Teach
the client 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 thrombosis in the legs)
C. Instruct the client to wear sequential compression stockings.
(Sequential compression devices (SCD's) promote venous blood flow, preventing VTE)
E. Explain that enoxaparin injections will be administered routinely.
(Enoxaparin 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?
A. Palpating bilateral pedal pulses
B. Assessing the capillary refill in the great toe
C. Assessing the Homan's sign in bilateral extremities
D. Applying light pressure in ankles to determine edema - Answer-C. Assessing the
Homan's sign in bilateral extremities.
, Homan's sign is "not a reliable indicator" and is a potentially dangerous method
because of possible clot dislodgement.
The client is wearing thigh-high antiembolic hose prescriber 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?
A. Paresthesia
B. Decreases hair growth in lower legs
C. Negative for pallor
D. Unilateral calf edema - Answer-D. Unilateral calf edema.
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 client's
legs when he is sitting?
A. Use two pillows and place one lengthwise under each calf.
B. Let him position himself with pillows until he is comfortable
C. Allow him to use the bed controls to markedly flex his knees
D. Encourage him to keep his legs flat and not bend his knees. - Answer-A. Use two
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
for venous thrombosis
Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is
1mg/kg subcutaneously every 12 hours. Dose available is 80 mg per 0.8 mL - Answer-
0.6
Nutritional Concerns
The client is 6 feet 2 inches tall and weighs 140 (63.5 kg). The nurse calculates his
Body Mass Index (BMI) as 18. The nurse continues the nutritional assessment. The
client's 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 colas.
Which nursing diagnosis best applies to the client's nutritional assessment?
A. Imbalanced nutrition: less than the body requirements
B. Imbalanced nutrition: more than body requirements
C. Risk for aspiration
D. Knowledge deficit: nutrition - Answer-A. Imbalanced nutrition: less than body
requirements.
