Mobility Case Study Exam Questions with Complete Answers

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.