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 D

Explanation

A. The colon does not secrete bile; bile is produced by the liver and stored in the gallbladder.
B. The colon does absorb electrolytes, but its primary function is water absorption, which helps form solid stool.
C. The colon does not secrete digestive enzymes; enzyme secretion occurs primarily in the stomach and small intestine.
D. The colon's primary function is absorbing large amounts of water, which helps maintain fluid balance and form feces. Disruptions, such as in colon cancer, can lead to diarrhea or constipation.

A. Have the client lay on their left side. B. Ask the client to exhale and hold their breath. C. Encourage the client to raise their head off the pillow. D. Assist the client in flexing their knees.

Correct Answer is D

Explanation

A. Lying on the left side does not aid in abdominal palpation and may not provide additional diagnostic information.
B. Asking the client to exhale and hold their breath is useful in certain liver or gallbladder assessments but is not relevant for general abdominal palpation.
C. Raising the head off the pillow is a technique used to assess for diastasis recti or hernias but is not beneficial for assessing right lower quadrant pain.
D. Assisting the client in flexing their knees is correct because it relaxes the abdominal muscles, reducing guarding and making palpation more effective. This is especially important when assessing for conditions like appendicitis.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is D

Explanation

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