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 D
Explanation
A. Loosen the client's bed linens:
For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.
B. Provide bright lights in the client's room:
Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.
C. Massage the client's sacrum:
Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.
D. Offer to play music in the client's room:
Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.
Correct Answer is C
Explanation
A. The hot water heater is set to 47° C (117° F).This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.
B. Grab bars are installed in the shower.Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.
C. There is an area rug covering a tile floor.Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.
D. Prescriptions are stored in a medication organizer.A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.
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