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 A

Explanation

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

A. Understanding of the referral process. B. Recognition of the client's medical prognosis. C. Drawing inferences about the client. D. Knowledge of anatomy and physiology.

Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

Correct Answer is A

Explanation

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

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