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 client's age is part of the measurement."
"Each element has a range from one to five points."
"The higher the score, the higher the pressure injury risk."
"The scale measures six elements."
The Correct Answer is D
Choice A Reason:
"The client's age is part of the measurement." - This is not accurate. The Braden scale does not include the client's age as part of the assessment. The elements evaluated are related to factors such as sensory perception, mobility, and nutrition, not age.
Choice B Reason:
"Each element has a range from one to five points." The Braden scale assesses a client's risk for developing pressure ulcers by evaluating six different elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each of these elements is scored from 1 to 5 points, with a higher score indicating better functioning or less risk for developing pressure injuries. Understanding that each element is scored on a scale from 1 to 5 is a fundamental aspect of using the Braden scale effectively.
Choice C Reason:
"The higher the score, the higher the pressure injury risk." - This is incorrect. In the Braden scale, a higher score indicates a lower risk of developing pressure injuries. Higher scores mean that the client has better functioning in the assessed elements, which reduces their risk.
Choice D Reason:
"The scale measures six elements." - This statement is true. The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. However, the response does not demonstrate an understanding of how each element is scored, which is the main focus of the scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A. Delirium can indeed affect a client's sleep cycle. Clients with delirium often experience disturbances in their sleep-wake cycle, with periods of agitation and confusion at night and drowsiness during the day.
Choice B Reason:
B. Delirium does not have a slow progression. It is a condition characterized by its abrupt and acute onset, which is in contrast to other cognitive disorders like dementia, which have a more gradual progression.
Choice C Reason:
"Delirium has an abrupt onset." This statement is accurate because delirium typically has a sudden and acute onset, with a rapid change in a person's mental state and cognitive function. Delirium is characterized by fluctuations in consciousness, attention, and cognitive function, and it can develop over hours to days.
Choice D Reason:
Delirium does affect a client's perception of their environment. Clients with delirium may have distorted perceptions, hallucinations, and misinterpretations of their surroundings, leading to significant cognitive and perceptual disturbances.
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
A. Performing a simple dressing change: This task is often routine and can be safely delegated to assistive personnel, provided they are trained and competent in performing dressing changes. Simple dressing changes typically do not require specialized nursing skills.
Choice B Reason:
Evaluating the healing of an incision: This task requires clinical judgment and assessment skills and should be performed by a licensed healthcare professional, such as a nurse, who can make clinical judgments about wound healing.
Choice C Reason:
Inserting an NG tube: NG tube insertion is a more complex and invasive procedure and should only be performed by healthcare professionals, such as nurses or physicians, with the necessary training and competency due to the potential risks and complications associated with NG tube insertion.
Choice D Reason:
Changing IV tubing: Routine IV tubing changes can be delegated to assistive personnel who have been trained in the proper procedure. It's important for the nurse to ensure that the personnel understand the specific protocol and infection control measures for IV tubing changes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today