A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
"Each element has a range from one to five points."
"The client's age is part of the measurement."
"The higher the score, the higher the pressure injury risk
The scale measures six elements
The Correct Answer is D
The Braden scale is a commonly used tool for assessing a patient's risk of developing pressure injuries (also known as pressure ulcers or bedsores). It evaluates six specific elements to determine the patient's risk level. These elements include sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element is assessed and assigned a score, with a lower score indicating a higher risk for developing pressure injuries.
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Correct Answer is C
Explanation
The client's emotional response is a normal reaction to the surgery and may be related to changes in her body image and self-esteem. By acknowledging the client's feelings, the nurse can establish a trusting relationship and help the client to cope with her situation. Encouraging the client to assist with her dressing changes or providing her with a mirror may be appropriate interventions later, but the nurse should address the client's emotional needs first. Referring the client to a breast cancer support group may also be appropriate, but this should be done in collaboration with the client after assessing her readiness and willingness to participate.
Correct Answer is A
Explanation
Delirium is an acute confusional state that develops rapidly over a short period of time, often within hours or days. It is characterized by a disturbance in consciousness and attention, along with changes in cognition and perception.
Delirium can significantly impact a client's perception of their environment. Clients with delirium may experience hallucinations, delusions, and misinterpretations of their surroundings. They may become disoriented, have difficulty recognizing familiar people or places, and exhibit altered levels of awareness and attention.
As mentioned earlier, delirium has an abrupt onset, meaning it develops rapidly. Delirium is usually a transient condition that fluctuates throughout the day, with symptoms varying in severity.
Delirium can disrupt a client's sleep-wake cycle. Clients with delirium may experience disturbances in their sleep patterns, such as difficulty falling asleep, frequent awakening during the night, or excessive sleepiness during the day.
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