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."
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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Related Questions
Correct Answer is A
Explanation
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.
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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