Mobility Case Study Exam Questions
with Complete Answers
The client is 6 feet 2 inches tall and weighs 140 lbs (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? - Answer-
Imbalanced nutrition: less than body requirements.
The client 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 the client to increase his intake of which foods to prevent a
decrease in bone density? - Answer-Calcium rich foods.
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? - Answer-Milk, oatmeal, and an orange.
As a part of the physical assessment of the client, the nurse utilizes the Braden Scale.
The nurse explains to the student nurse that the Braden Scale is used to measure
which client parameter? - Answer-Risk for pressure sores.
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? - Answer-Reposition the client in
bed from supine to a 30 degree side-lying position every 2 hours.
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? - Answer-Position the chair at the head of the bed facing the foot on the
client's left side close to the bed.
The nurse is in the room when the client quickly gets up out of bed to go to the
bathroom. With the nurse's assistance, the client 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 the client to the floor.
, After sitting on the floor for a few minutes, the client is helped to a standing position by
the nurse. He is able to walk to the bathroom and back to bed without further problems.
After the client is safely back in bed, the nurse believes the client may have had an
episode orthostatic hypotension.
How should the nurse assess for orthostatic hypotension? - Answer-Take the client's
blood pressure and pulse while the client is in the lying, sitting, and standing positions.
The nurse hears the client cough and realizes the client is at risk for pneumonia due to
lack of movement. The nurse performs a lung assessment and auscultates fine crackles
bilaterally in the upper lobes. The client states that because he has smoked for 40
years, he always has a cough in the morning.
Which action should the nurse implement? - Answer-Teach the client to take ten deep
breaths an hour while awake.
The nurse demonstrates the proper technique for deep breathing. When the client
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.
The client is concerned that he may become constipated due to his lack of activity and
poor diet.
Which educational information would the nurse provide the client to help prevent
constipation? (Select all that apply. One, some, or all options may be correct.) -
Answer--Increase physical activity as tolerated.
-Drink plenty water.
-Choose foods higher in fiber.
The nurse also develops a dietary teaching plan to reduce the risk of constipation.
Which dietary selection should the nurse encourage the client to eat? - Answer-Chicken
Caesar salad with a whole wheat roll and skim milk.
The nurse notices a religious book in the client's room. While talking with him, he asks
the nurse to hand him the religious book.
Which is the best therapeutic approach for the nurse to engage in conversation with the
client? - Answer-"I sense a spiritual strength about you."
The client 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 the client's spiritual needs?
- Answer-Place a sign on the door to allow the client some quiet time in the mornings.
The client 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.
with Complete Answers
The client is 6 feet 2 inches tall and weighs 140 lbs (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? - Answer-
Imbalanced nutrition: less than body requirements.
The client 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 the client to increase his intake of which foods to prevent a
decrease in bone density? - Answer-Calcium rich foods.
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? - Answer-Milk, oatmeal, and an orange.
As a part of the physical assessment of the client, the nurse utilizes the Braden Scale.
The nurse explains to the student nurse that the Braden Scale is used to measure
which client parameter? - Answer-Risk for pressure sores.
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? - Answer-Reposition the client in
bed from supine to a 30 degree side-lying position every 2 hours.
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? - Answer-Position the chair at the head of the bed facing the foot on the
client's left side close to the bed.
The nurse is in the room when the client quickly gets up out of bed to go to the
bathroom. With the nurse's assistance, the client 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 the client to the floor.
, After sitting on the floor for a few minutes, the client is helped to a standing position by
the nurse. He is able to walk to the bathroom and back to bed without further problems.
After the client is safely back in bed, the nurse believes the client may have had an
episode orthostatic hypotension.
How should the nurse assess for orthostatic hypotension? - Answer-Take the client's
blood pressure and pulse while the client is in the lying, sitting, and standing positions.
The nurse hears the client cough and realizes the client is at risk for pneumonia due to
lack of movement. The nurse performs a lung assessment and auscultates fine crackles
bilaterally in the upper lobes. The client states that because he has smoked for 40
years, he always has a cough in the morning.
Which action should the nurse implement? - Answer-Teach the client to take ten deep
breaths an hour while awake.
The nurse demonstrates the proper technique for deep breathing. When the client
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.
The client is concerned that he may become constipated due to his lack of activity and
poor diet.
Which educational information would the nurse provide the client to help prevent
constipation? (Select all that apply. One, some, or all options may be correct.) -
Answer--Increase physical activity as tolerated.
-Drink plenty water.
-Choose foods higher in fiber.
The nurse also develops a dietary teaching plan to reduce the risk of constipation.
Which dietary selection should the nurse encourage the client to eat? - Answer-Chicken
Caesar salad with a whole wheat roll and skim milk.
The nurse notices a religious book in the client's room. While talking with him, he asks
the nurse to hand him the religious book.
Which is the best therapeutic approach for the nurse to engage in conversation with the
client? - Answer-"I sense a spiritual strength about you."
The client 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 the client's spiritual needs?
- Answer-Place a sign on the door to allow the client some quiet time in the mornings.
The client 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.
