HESI MOBILITY CASE STUDY EXAM 1 UPDATED QUESTIONS AND
ANSWERS
Case study info - CORRECT ANSWER✅✅Meet the Client: John Mathis
John Mathis, a 73-year-old male, is treated in the emergency department (ED) for an infected wound on
his right foot. John states he was walking barefoot and stepped on something sharp that cut his foot. He
treated it with topical antibiotics, but it appears red and inflamed, with purulent drainage. John is
admitted to the medical-surgical unit for inpatient wound care treatment.
Mr. Matthew tells the nurse that he has never been hospitalized. He appears anxious and frequently
turns to his wife for reassurance. What is the best response by the nurse? - CORRECT
ANSWER✅✅"What concerns do you have about being hospitalized?"
This response utilizes principles of therapeutic communication. It is an open-ended question designed to
allow Mr. Matthew to verbalize any concerns about hospitalization that might be contributing to his
anxiety.
Mr. Matthew tells the nurse, "My sweetheart and I have never been apart during our 55-year marriage."
What action should the nurse implement to help reduce Mr. Matthew's anxiety during the admission
process? - CORRECT ANSWER✅✅Explain the room environment to Mr. and Mrs. Matthew.
This action will reduce the client's anxiety by including the spouse, and orienting them both to the room.
Mr. Matthew states the pain level in his right foot is 8 on a scale of 1-10. He says he has been favoring
his foot by staying in bed the past week. In planning his care, which nursing diagnosis should take
priority? - CORRECT ANSWER✅✅Impaired physical mobility.
Mr. Matthew's limited activities support this nursing diagnosis. Improving mobility is a nursing priority
to prevent the many potential complications.
In developing a plan of care, the nurse consults with Mr. Matthew to identify a short-term goal. Which
goal is correct for Mr. Matthew's diagnosis for impaired mobility? - CORRECT 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. Matthew is to achieve and sets a realistic deadline.
Mr. Matthew 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. Which instruction should the nurse convey to help prevent venous thrombosis in Mr.
Matthew's legs? - CORRECT ANSWER✅✅-Teach Mr. Matthew 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 prevent venous thrombosis
in the legs)
-Instruct Mr. Mathis to wear sequential compression stockings.
-Explain that enoxaparin injections will be administered routinely.
--------------
An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you
have a lung illness, such as pneumonia
How should the nurse document the completed client teaching? - CORRECT ANSWER✅✅Dorsal and
plantar flexion demonstrated to client and returned correctly. States he will perform 10 times an hour.
This represents a complete documentation, which includes the content taught and a statement of the
client's understanding after the teaching.
The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis. Which action
requires the nurse to intervene? - CORRECT ANSWER✅✅Assessing the Homan's sign in bilateral
extremities.
Homans' sign. : pain in the calf of the leg upon dorsiflexion of the foot with the leg extended that is
diagnostic of thrombosis in the deep veins of the area.----
ANSWERS
Case study info - CORRECT ANSWER✅✅Meet the Client: John Mathis
John Mathis, a 73-year-old male, is treated in the emergency department (ED) for an infected wound on
his right foot. John states he was walking barefoot and stepped on something sharp that cut his foot. He
treated it with topical antibiotics, but it appears red and inflamed, with purulent drainage. John is
admitted to the medical-surgical unit for inpatient wound care treatment.
Mr. Matthew tells the nurse that he has never been hospitalized. He appears anxious and frequently
turns to his wife for reassurance. What is the best response by the nurse? - CORRECT
ANSWER✅✅"What concerns do you have about being hospitalized?"
This response utilizes principles of therapeutic communication. It is an open-ended question designed to
allow Mr. Matthew to verbalize any concerns about hospitalization that might be contributing to his
anxiety.
Mr. Matthew tells the nurse, "My sweetheart and I have never been apart during our 55-year marriage."
What action should the nurse implement to help reduce Mr. Matthew's anxiety during the admission
process? - CORRECT ANSWER✅✅Explain the room environment to Mr. and Mrs. Matthew.
This action will reduce the client's anxiety by including the spouse, and orienting them both to the room.
Mr. Matthew states the pain level in his right foot is 8 on a scale of 1-10. He says he has been favoring
his foot by staying in bed the past week. In planning his care, which nursing diagnosis should take
priority? - CORRECT ANSWER✅✅Impaired physical mobility.
Mr. Matthew's limited activities support this nursing diagnosis. Improving mobility is a nursing priority
to prevent the many potential complications.
In developing a plan of care, the nurse consults with Mr. Matthew to identify a short-term goal. Which
goal is correct for Mr. Matthew's diagnosis for impaired mobility? - CORRECT 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. Matthew is to achieve and sets a realistic deadline.
Mr. Matthew 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. Which instruction should the nurse convey to help prevent venous thrombosis in Mr.
Matthew's legs? - CORRECT ANSWER✅✅-Teach Mr. Matthew 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 prevent venous thrombosis
in the legs)
-Instruct Mr. Mathis to wear sequential compression stockings.
-Explain that enoxaparin injections will be administered routinely.
--------------
An incentive spirometer is a device used to help you keep your lungs healthy after surgery or when you
have a lung illness, such as pneumonia
How should the nurse document the completed client teaching? - CORRECT ANSWER✅✅Dorsal and
plantar flexion demonstrated to client and returned correctly. States he will perform 10 times an hour.
This represents a complete documentation, which includes the content taught and a statement of the
client's understanding after the teaching.
The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis. Which action
requires the nurse to intervene? - CORRECT ANSWER✅✅Assessing the Homan's sign in bilateral
extremities.
Homans' sign. : pain in the calf of the leg upon dorsiflexion of the foot with the leg extended that is
diagnostic of thrombosis in the deep veins of the area.----
