A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?

Morse Scale

Braden Scale

Bristol Scale

Hendrich II scale

Answer and Explanation

The Correct Answer is B

A. Morse Scale:

The Morse Scale, also known as the Morse Fall Scale, is used to assess a patient's risk of falling. It evaluates various factors such as history of falling, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status. It is primarily focused on assessing the risk of falls, not pressure ulcers.
B. Braden Scale:

As previously mentioned, the Braden Scale assesses a patient's risk for developing pressure ulcers. It takes into account sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The scale helps healthcare providers determine the level of risk a patient has for developing pressure sores and guides interventions to prevent them.

C. Bristol Scale:

The Bristol Stool Scale is used to classify the form of human feces into seven categories. It is a medical aid designed to classify the form of human feces into seven categories. This scale is primarily used to assess bowel movements and is unrelated to pressure ulcers.
D. Hendrich II Scale:

The Hendrich II Fall Risk Model is a tool designed to identify patients at risk for falls. It includes factors such as confusion, symptomatic depression, altered elimination, dizziness, male gender, and the use of antiepileptics, benzodiazepines, or non-opioid analgesics. Similar to the Morse Scale, it focuses on assessing the risk of falls, not pressure ulcers.

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Correct Answer is D

Explanation

A. McBurney's point on the abdomen: McBurney's point is a location in the right lower quadrant of the abdomen that is significant in the assessment for appendicitis. It is not relevant to the assessment of pyelonephritis, which is a kidney infection.

B. Psoas sign at the knee: The psoas sign is a test for appendicitis, not pyelonephritis. It involves the patient lying on their back and lifting their right leg against resistance. If this movement causes pain in the lower right abdomen, it could indicate irritation of the psoas muscle due to an inflamed appendix.

C. Rovsing's Sign on the abdomen: Rovsing's sign is also a test for appendicitis. It involves palpating the left lower quadrant of the abdomen and observing if it causes pain in the right lower quadrant. The presence of pain in the right lower quadrant during palpation of the left lower quadrant can indicate appendicitis. This sign is not specific to pyelonephritis.

D. Costovertebral angle (CVA) on the back: The CVA is located on the back at the angle formed by the 12th rib and the spine. Percussion of the CVA is a common technique used to assess for kidney tenderness. In the case of acute pyelonephritis, infection and inflammation of the kidneys can cause tenderness and pain in the CVA area. Therefore, this area is assessed for pain related to kidney infections like pyelonephritis.

A. Provide the client with antipyretic therapy. B. Administer antibiotics to the client. C. Teach relaxation breathing to reduce the client's pain. D. Increase the client's protein intake.

Correct Answer is B

Explanation

A. Provide the client with antipyretic therapy. - Antipyretic therapy can help reduce fever, but addressing the underlying infection with antibiotics is crucial.

B. Administer antibiotics to the client. -The priority intervention for a client with acute osteomyelitis is to administer antibiotics promptly. Osteomyelitis is a severe bacterial infection of the bone, which requires aggressive antibiotic therapy to eradicate the infection. Delaying antibiotic treatment can lead to further complications and the spread of the infection.

C. Teach relaxation breathing to reduce the client's pain. - Pain management is important, but in the case of acute osteomyelitis, the priority is to eliminate the infection through antibiotics.

D. Increase the client's protein intake. - Adequate nutrition, including protein, is important for overall healing and immune function, but it is not the priority when dealing with an acute infection that requires immediate antibiotic treatment.

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A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with acute pyelonephritis. Which area should the nurse percuss to assess for pain related to pyelonephritis?

Correct Answer is D

Explanation

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Correct Answer is B

Explanation

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