HESI Mobility Case Study Guide Exam
Questions with Correct Answers
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.
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? - Answer-
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? - Answer-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? -
Answer-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? -
Answer-"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? - Answer-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? - Answer-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? - Answer-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,
Questions with Correct Answers
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.
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? - Answer-
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? - Answer-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? -
Answer-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? -
Answer-"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? - Answer-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? - Answer-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? - Answer-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,
