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?

"The scale measures six elements."

"The client's age is part of the measurement."

"The higher the score, the higher the pressure injury risk."

"Each element has a range from one to five points."

Answer and Explanation

The Correct Answer is A

A.   The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B.   The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C.   In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D.   Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.

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Correct Answer is A

Explanation

A. Eyelashes that curl slightly outward is a normal finding.
B. Eyelids that blink involuntarily 30 to 35 times per minute may be a normal range, but it's not typically assessed during a routine eye examination.
C. Pupils of 8 to 9 mm in diameter might indicate dilation, which is not a normal finding during a regular eye assessment.
D. Corneas with an opaque appearance could indicate issues such as corneal edema or opacity, which are abnormal findings.

A. A sharp decrease in blood pressure B. A feeling of swelling in the feet C. Pain at the injection site D. A sudden decrease in heart rate

Correct Answer is A

Explanation

A. Anaphylactic reactions can cause a sudden and severe drop in blood pressure, which is a potentially life-threatening symptom. It's a hallmark sign of anaphylaxis.
B. A feeling of swelling in the feet might indicate a localized reaction but is less specific to anaphylaxis.
C. Pain at the injection site might occur due to local irritation but isn't typically a primary sign of an anaphylactic reaction.
D. A sudden decrease in heart rate is not a typical sign of an anaphylactic reaction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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