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.
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.