Mobility HESI: HESI Mobility
Which information is most important for the nurse to obtain in the initial assessment?(Ans- "Tell me about concerns you have about being hospitalized."
What action should the nurse implement to help reduce Mr.Mathis' anxiety during the admission process?(Ans- Explain the room environment to Mr. and Mrs. Mathis.
When care is planned for Mr. Mathis, which nursing diagnosis should take priority?(Ans- Impaired physical mobility.
Which goal is correct for Mr. Mathis' diagnosis of impaired physical mobility?(Ans- The client will sit in the chair for each meal beginning on the day of admission.
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Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in Mr. Mathis' legs?(Ans- -Teach Mr. Mathis to dorsal flex and plantar flex his feet while in the bed and chair.-Instruct Mr. Mathis to wear sequential compression stockings.-Explain that enoxaparin injections will be administered routinely.
The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis. Which action requires the nurse to intervene?(Ans- Assessing the Homan's sign in bilateral extremities.
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?(Ans- Unilateral calf edema.
Which instruction should the nurse give to the unlicensed assistive personnel (UAP) for positioning Mr. Mathis' legs?(Ans- Use two pillows and place one lengthwise under each calf.
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