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

"The scale measures six elements."

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

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

Answer and Explanation

The Correct Answer is B

B. The Braden scale is an evidence-based tool used in healthcare to assess a patient's risk for developing pressure injuries. It evaluates six factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

A. The higher the score, the lower the risk of pressure injury.

C. the client's age is not part of the measurement

D. Each element is rated from 1 to 4, not 1 to 5.

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Correct Answer is ["B","D"]

Explanation

B. Vitamin D level- Low levels of vitamin D, as indicated by the client's 25-hydroxy D (vitamin D + D) levels below the reference range (24 ng/dL initially and 15 ng/dL at the 6-month follow-up), can contribute to osteoporosis. Vitamin D is essential for calcium absorption and bone health.

D. Activity level- The client reports a sedentary lifestyle and inability to exercise regularly. Lack of weight-bearing exercise can increase the risk of osteoporosis as weight-bearing exercises help maintain bone density.
A. Alcohol use- The client denies drinking alcohol, so alcohol use is not a risk factor in this case.
C. Lactose intolerant- Lactose intolerance does not directly increase the risk of osteoporosis. However, if the client avoids dairy products due to lactose intolerance, they may have lower calcium intake, which can affect bone health.
E. Smoking history- The client is described as a nonsmoker, so smoking is not a risk factor for osteoporosis in this case. Smoking is associated with decreased bone density and increased fracture risk.
F. Phosphorus level- Phosphorus levels within the normal range (3.4 mg/dL initially and 3.2 mg/dL at the 6-month follow-up) do not directly indicate increased risk for osteoporosis. However, phosphorus, along with calcium, is important for bone health.

A. Respiratory rate B. Weight C. Level of orientation D. Current pain level

Correct Answer is B

Explanation

Rationale
B. Weight is a key component of the anthropometric assessment as it provides important information about the client's nutritional status, growth patterns, and overall health. Changes in weight can indicate changes in body composition, hydration status, or underlying health conditions.
A. Respiratory rate is not part of the anthropometric assessment
C. level of orientation is not part of the anthropometric assessment
D. current pain level is not part of the anthropometric assessment.

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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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Correct Answer is ["B","D"]

Explanation

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Correct Answer is B

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