which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

Correct answer: C

Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.

2. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

Correct answer: A

Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.

3. An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:

Correct answer: D

Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.

4. Which client is most likely to be at risk for spiritual distress?

Correct answer: A

Rationale: The correct answer is A. In Roman Catholicism, abortion is strictly prohibited, so a Roman Catholic woman considering this procedure may experience spiritual distress due to conflicts with her religious beliefs. This conflict can lead to emotional and psychological turmoil, affecting her spiritual well-being. It is essential for healthcare providers to recognize and address such conflicts with sensitivity and understanding to provide holistic care.

5. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

Correct answer: B

Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.

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