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."

Answer and Explanation

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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Correct Answer is B

Explanation

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

A. Lactose intolerant, B. Alcohol use C. Smoking history D. Phosphorous level E. Activity level F. Vitamin D level

Correct Answer is ["A","B","C","F"]

Explanation

Correct responses

A. Lactose intolerant: Lactose intolerance can lead to lower dairy intake, which may reduce calcium intake, increasing the risk of osteoporosis.

B. Alcohol use: Excessive alcohol consumption can interfere with calcium absorption and bone health, increasing the risk of osteoporosis.

C. Smoking history: Smoking is associated with decreased bone density and increased risk of osteoporosis due to its negative effects on bone metabolism.

F. Vitamin D level: The client's vitamin D levels are below the recommended range. Vitamin D is crucial for calcium absorption and bone health, so insufficient levels can increase the risk of osteoporosis.

The other factors are less directly related to osteoporosis risk in this client:

D. Phosphorous level: The phosphorous level is within the normal range and is not directly linked to osteoporosis risk.

E. Activity level: The activity level is not provided in the information; however, physical activity is generally important for bone health. If the client is sedentary, it could be a risk factor, but it's not specified here.

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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

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","F"]

Explanation

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