Mobility Exam Questions with Complete
Answers
Which goal is correct for Mr. Mathis' diagnosis of impaired physical mobility?
- The client will transfer to the chair with assist of one person.
- The nurse will reposition the client every hour while the client is awake.
- The client will sit in the chair for each meal beginning on the day of admission.
- The nurse will assist the client to ambulate in the hall by the second hospital day. -
Answer-- The client will sit in the chair for each meal beginning on the day of admission.
(This is a correctly stated goal. The client is always the subject of the goal, and the
action is always measurable. This goal includes what Mr. Mathis is to achieve and sets
a realistic deadline.)
Mr. Mathis is reluctant to move in the bed or move to the chair. He likes his wife to place
a pillow under his knee. The nurse performs a physical assessment, which reveals
diminished dorsalis pedis pulses bilaterally. - Answer-...
Which instructions should the nurse convey to help prevent venous thromboembolism
(VTE) in Mr. Mathis' legs?
Select all that apply
- Encourage Mr. Mathis to use the incentive spirometer 10 times an hour while awake.
- Teach Mr. Mathis to dorsal flex and plantarflex his feet while in the bed and chair.
- Instruct Mr. Mathis to wear sequential compression stockings.
- Advise Mr. Matthew to try not to move and cause pain in his foot wound.
- Explain that enoxaparin injections will be administered routinely. - Answer-- Teach Mr.
Mathis to dorsal flex and plantar flex his feet while in the bed and chair.
(This action stimulates circulation by contracting calf muscles, which increases the
venous return of blood to the heart. This decreases pooling of blood in the legs, which
helps VTE in the legs.)
- Instruct Mr. Mathis to wear sequential compression stockings.
(Sequential compression devices (SCD) promote venous blood flow, preventing VTE.)
- Explain that enoxaparin injections will be administered routinely.
(Enoxaparin is an anticoagulant that is administered to reduce the risk of VTE.)
The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis.
Which action requires the nurse to intervene?
- Palpating bilateral pedal pulses.
, - Assessing the capillary refill in the great toe.
- Assessing the Homan's sign in bilateral extremities.
- Applying light pressure in ankles to determine edema. - Answer-- Assessing the
Homan's sign in bilateral extremities.
(Homan's sign is a potentially dangerous method because of possible clot
dislodgement.)
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.)
Answers
Which goal is correct for Mr. Mathis' diagnosis of impaired physical mobility?
- The client will transfer to the chair with assist of one person.
- The nurse will reposition the client every hour while the client is awake.
- The client will sit in the chair for each meal beginning on the day of admission.
- The nurse will assist the client to ambulate in the hall by the second hospital day. -
Answer-- The client will sit in the chair for each meal beginning on the day of admission.
(This is a correctly stated goal. The client is always the subject of the goal, and the
action is always measurable. This goal includes what Mr. Mathis is to achieve and sets
a realistic deadline.)
Mr. Mathis is reluctant to move in the bed or move to the chair. He likes his wife to place
a pillow under his knee. The nurse performs a physical assessment, which reveals
diminished dorsalis pedis pulses bilaterally. - Answer-...
Which instructions should the nurse convey to help prevent venous thromboembolism
(VTE) in Mr. Mathis' legs?
Select all that apply
- Encourage Mr. Mathis to use the incentive spirometer 10 times an hour while awake.
- Teach Mr. Mathis to dorsal flex and plantarflex his feet while in the bed and chair.
- Instruct Mr. Mathis to wear sequential compression stockings.
- Advise Mr. Matthew to try not to move and cause pain in his foot wound.
- Explain that enoxaparin injections will be administered routinely. - Answer-- Teach Mr.
Mathis to dorsal flex and plantar flex his feet while in the bed and chair.
(This action stimulates circulation by contracting calf muscles, which increases the
venous return of blood to the heart. This decreases pooling of blood in the legs, which
helps VTE in the legs.)
- Instruct Mr. Mathis to wear sequential compression stockings.
(Sequential compression devices (SCD) promote venous blood flow, preventing VTE.)
- Explain that enoxaparin injections will be administered routinely.
(Enoxaparin is an anticoagulant that is administered to reduce the risk of VTE.)
The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis.
Which action requires the nurse to intervene?
- Palpating bilateral pedal pulses.
, - Assessing the capillary refill in the great toe.
- Assessing the Homan's sign in bilateral extremities.
- Applying light pressure in ankles to determine edema. - Answer-- Assessing the
Homan's sign in bilateral extremities.
(Homan's sign is a potentially dangerous method because of possible clot
dislodgement.)
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.)
