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 client's age is part of the measurement."
"Each element has a range from one to five points."
"The scale measures six elements."
The Correct Answer is D
A. "The higher the score, the higher the pressure injury risk.": The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.
B. "The client's age is part of the measurement.": The client’s age is not a direct factor measured by the Braden Scale.
C. "Each element has a range from one to five points.": Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.
D. "The scale measures six elements.":
The Braden Scale evaluates six elements: Sensory perception, Moisture, Activity, Mobility, Nutrition and Friction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.
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Related Questions
Correct Answer is A
Explanation
A. Assault:
Assault occurs when one person intentionally threatens or causes another person to fear that they will be touched without their consent. In this situation, the nurse is threatening to administer medication by injection (an unwanted touch) as a consequence for not swallowing pills.
B. Invasion of privacy:
Invasion of privacy involves the unauthorized intrusion into an individual's personal matters. The nurse's statement does not relate to invading the client's privacy; it involves a threat related to the administration of medication.
C. Defamation:
Defamation involves making false statements that harm the reputation of another person. The nurse's statement is not making false statements about the client but rather threatening a specific action if a behavior is not followed.
D. Battery:
Battery occurs when there is intentional physical contact with another person without their consent. While the nurse's statement involves the administration of medication, the threat itself is considered assault. If the threat is carried out, and the medication is administered against the client's will, it would then be considered battery.
Correct Answer is B
Explanation
A. "You need to understand that you have very little time left":
This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.
B. "I will contact your provider to discuss your options":
This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan
C. "Enjoy the time you have and do the things you want to do":
This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.
D. "Hospice care is the best thing for you at this time":
While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.
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