concepts mobility hesi case study – Flashcards
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what concerns do you have about being hospitalized
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As part of the admission interview the nurse asks mr matthew and his wife how they would like to be addressed by the staff
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explain the room environment to him
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Mr matthew says my sweatheart and i have never been apart
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impaired physical mobility
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Mr. Matthew state the pain level is 8 out of 10 in foot etc.
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the client will sit in the chair for each meal beginning on the day of admission
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in developing a plan of care the nurse consults with mr. matthew to identify a short term goal
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teach him to flex his feet in bed explain enoxaparin(Lovenox injections will be administered routinely
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which instructions should the nurse convey to help prevent venous thromboembolism?
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dorsal and plantar flexion demonstrated to client and returned correctly stated he will perform 10 times an hour
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how should the nurse document teaching?
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unilateral calf edema positive homans sign
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which assessment reflects possible DVT
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imbalanced nutrition:less than body requirements
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mr matthews BMI is 18.
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calcium rich foods
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which foods are to prevent a decrease in bone density?
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milk oatmeal and an orange
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which foods should the nurse encourage?
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position the chair at a 45 degree on mr matthews left side
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right leg weakness in a hospital bed
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priority is to lower mr matthew to the floor
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he feels faint and is 5 feet from the bed
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you probably experienced postural hypotension let me explain
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how should the nurse explain this dizziness to the client?
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teach him to take ten deep breaths an hour while awake.
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he has fine crackles while breathing and is at risk for pneumonia.
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help the client perform the correct technique for DEEP breathing .
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mr matthew is raising his shoulders while he is breathing.
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risk for pressure sores
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The braden scale is for:
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reposition mr matthew in bed from supine to 60 degree side lying position every two hours.
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He is at risk for pressure sores. what should the nurse do?
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1st thing is to ask about allergies
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The healthcare provider prescribed an oral antibiotic for mr matthew on admission to the hospital to treat the ulcer on his right foot
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add buttermilk or active culture yogurt to the diet daily
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during the course of antibiotics he should what?
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teach mr matthew to perform exercises such as gluteal sets and quadriceps sets 5 times every 2 hours while awake.
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mr matthew has stayed in bed for a weak and the nurse is worried about muscle atrophy.
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ask the UAP to assist mr matthew in taking a complete bed bath
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In planning morning care for mr matthew what action should the nurse take?
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offer to obtain a bedside commode for mr matthew
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mr matthew is concerned that he may become constipated due to his lack of activity and poor diet
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increase vegetables fresh fruit and dried fruits
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a dietary plan to help this would include:
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i sense a spiritual strength about you
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the nurse notices a bible in the mr matthew room. While talking to him the nurse senses a serenity about him
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place a sign on the door to allow mr matthew some quiet time in the morning.
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what should the nurse do to provide for mr matthews spiritual needs?
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readiness for enhanced spiritual well being
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mr matthew says he has faith that God will be with him through this challenge to regain his health
