Mobility Exam Questions with Complete Answers

Mobility Exam Questions with Complete Answers 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? - Negative for paresthesia. - Decreases hair growth in lower legs. - Negative for pallor. - Unilateral calf edema. - Answer-- 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 unlicensed assistive personnel (UAP) for positioning Mr. Mathis' legs? - Use two pillows and place one lengthwise under each calf. - Let him position himself with pillows until he is comfortable. - Allow him to use the bed controls to markedly flex his knees. - Encourage him to keep his legs flat and not bend his knees. - Answer-- 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.) Mr. Mathis 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. Mrs. Mathis tells the nurse that she cooks every day, but Mr. Mathis does not even eat his favorite foods anymore, although he does drink a lot of diet colas. - Answer-... Which nursing diagnosis best applies to Mr. Mathis' nutritional assessment? - Imbalanced nutrition: less than body requirements. - Imbalanced nutrition: more than body requirements. - Risk for aspiration. - Knowledge deficit: nutrition. - 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.)