A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position.

The client's history of integumentary disorders.

The pigmentation of the client's skin.

The client's current medication regimen.

Answer and Explanation

The Correct Answer is A

A. The client's ability to change position is correct. The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Limited mobility increases the risk for pressure injuries.
B. A history of integumentary disorders is not part of the Braden Scale assessment. The scale focuses on current risk factors rather than past dermatologic conditions.
C. Skin pigmentation is not a factor in pressure ulcer risk assessment. However, in clients with darker skin, early signs of pressure injuries may be harder to detect due to lack of visible blanching.
D. Medications are not directly included in the Braden Scale. While some medications (e.g., steroids) can increase pressure injury risk, the Braden Scale does not specifically assess them.

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Correct Answer is B

Explanation

A. Increased urinary output is incorrect because NSAIDs like ibuprofen can cause kidney damage, leading to fluid retention and decreased urine output, not increased output.
B. Increased heart rate is correct. Long-term NSAID use can cause gastrointestinal (GI) irritation and ulcers, which may lead to occult blood loss and anemia. Anemia can result in tachycardia (increased heart rate) as the body compensates for decreased oxygen delivery. C. Decreased heart rate is incorrect because anemia and pain typically cause tachycardia, not bradycardia.
D. Hypoglycemia is incorrect because NSAIDs do not significantly impact blood glucose levels.

A. The client's infection is no longer localized and has become systemic. B. The client likely has a cardiac health problem, not a respiratory health problem. C. The client's signs and symptoms are related to hypothermia rather than infection. D. The client's normothermic temperature does not rule out the presence of an infection.

Correct Answer is D

Explanation

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

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A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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