HESI Case Study: Mobility Exam
Questions with Correct Answers
The nurse is observing a student nurse perform a peripheral assessment on the client.
Which action requires the nurse to intervene? - Answer-C) Assessing the Homan's sign
in bilateral extremities.
Rationale:
Homan's sign is "not a reliable indicator" and is a potentially dangerous method
because of possible clot dislodgment.
Which instruction should the nurse give to the nursing student for positioning the client's
legs when he is sitting? - Answer-A) Use two pillows and place one lengthwise under
each calf.
Rationale:
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.
The client is wearing thigh-high Anti embolic hose prescribed 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? -
Answer-D) Unilateral calf edema.
Rationale:
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be
reported to the HCP.
Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is
1mg/kg subcutaneously every 12 hours and the client weighs 140 lbs. Dose available is
80mg per 0.8 mL. How many milliliters will the nurse administer to the client? (Enter the
numeric value only. If rounding is necessary, round to the nearest tenth.) - Answer-140
lb / 2.2 lb = 63 kg
63kg x 1 mg = 63 mg
63 mg/ 80 mg = 0.7875
0.7875 x 0.8 ml = 0.63 ml
0.63 ml (Round) = 0.6 ml
Which nursing diagnosis best applies to the client's nutritional assessment? - Answer-A)
Imbalanced nutrition: less than body requirements.
Rationale:
, 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.
The nurse instructs the client to increase his intake of which foods to prevent a
decrease in bone density? - Answer-C) Calcium rich foods.
Rationale:
Calcium must be deposited in the bone to increase bone density.
Which foods should the nurse encourage? - Answer-A) Milk, oatmeal, and an orange.
Rationale:
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 and
D.
The nurse explains to the student nurse that the Braden Scale is used to measure
which client parameter? - Answer-B) Risk for pressure sores.
Rationale:
The Braden Scale assesses many risk factors that may contribute to pressure sores.
The factors that are assessed are nutrition, the ability to move, the degree of activity,
moisture on the skin, sensory perception, and friction and shear. A lower score indicates
a higher risk for pressure sores.
Which nursing action should be included in the plan? - Answer-B) Reposition the client
in bed from supine to a 30-degree side-lying position every 2 hours.
Rationale:
The client should be repositioned every 2 hours. The 30-degree angle for the lateral
position provides comfort without placing excessive pressure on the greater trochanter.
How should the nurse teach the student nurse to position the chair to ensure a safe
transfer? - Answer-D) Position the chair at the head of the bed facing the foot on the
client's left side close to the bed.
Rationale:
Placing the chair at the head of the bed on the stronger left side provides for a safe
transfer because it allows him to pivot easily from the bed into the chair.
What is the priority nursing action? - Answer-A) Gently lower the client to the floor.
Rationale:
This is the priority nursing action to prevent injury to the client and the nurse. Lowering
the client to the floor should be done when he cannot support his own weight.
Questions with Correct Answers
The nurse is observing a student nurse perform a peripheral assessment on the client.
Which action requires the nurse to intervene? - Answer-C) Assessing the Homan's sign
in bilateral extremities.
Rationale:
Homan's sign is "not a reliable indicator" and is a potentially dangerous method
because of possible clot dislodgment.
Which instruction should the nurse give to the nursing student for positioning the client's
legs when he is sitting? - Answer-A) Use two pillows and place one lengthwise under
each calf.
Rationale:
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.
The client is wearing thigh-high Anti embolic hose prescribed 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? -
Answer-D) Unilateral calf edema.
Rationale:
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be
reported to the HCP.
Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is
1mg/kg subcutaneously every 12 hours and the client weighs 140 lbs. Dose available is
80mg per 0.8 mL. How many milliliters will the nurse administer to the client? (Enter the
numeric value only. If rounding is necessary, round to the nearest tenth.) - Answer-140
lb / 2.2 lb = 63 kg
63kg x 1 mg = 63 mg
63 mg/ 80 mg = 0.7875
0.7875 x 0.8 ml = 0.63 ml
0.63 ml (Round) = 0.6 ml
Which nursing diagnosis best applies to the client's nutritional assessment? - Answer-A)
Imbalanced nutrition: less than body requirements.
Rationale:
, 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.
The nurse instructs the client to increase his intake of which foods to prevent a
decrease in bone density? - Answer-C) Calcium rich foods.
Rationale:
Calcium must be deposited in the bone to increase bone density.
Which foods should the nurse encourage? - Answer-A) Milk, oatmeal, and an orange.
Rationale:
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 and
D.
The nurse explains to the student nurse that the Braden Scale is used to measure
which client parameter? - Answer-B) Risk for pressure sores.
Rationale:
The Braden Scale assesses many risk factors that may contribute to pressure sores.
The factors that are assessed are nutrition, the ability to move, the degree of activity,
moisture on the skin, sensory perception, and friction and shear. A lower score indicates
a higher risk for pressure sores.
Which nursing action should be included in the plan? - Answer-B) Reposition the client
in bed from supine to a 30-degree side-lying position every 2 hours.
Rationale:
The client should be repositioned every 2 hours. The 30-degree angle for the lateral
position provides comfort without placing excessive pressure on the greater trochanter.
How should the nurse teach the student nurse to position the chair to ensure a safe
transfer? - Answer-D) Position the chair at the head of the bed facing the foot on the
client's left side close to the bed.
Rationale:
Placing the chair at the head of the bed on the stronger left side provides for a safe
transfer because it allows him to pivot easily from the bed into the chair.
What is the priority nursing action? - Answer-A) Gently lower the client to the floor.
Rationale:
This is the priority nursing action to prevent injury to the client and the nurse. Lowering
the client to the floor should be done when he cannot support his own weight.
