It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Weakened cough effort.

Hypoactive bowel sounds.

Urinary incontinence.

Plus two ankle edema.

Answer and Explanation

The Correct Answer is C

C. Urinary incontinence affects the moisture component of the Braden scale. Proper assessment and interventions are crucial to prevent skin breakdown.

A. A weakened cough effort is not directly related to pressure ulcer risk assessment, which is the purpose of the Braden Scale.

B. Bowel sounds are not included in the Braden Scale assessment criteria.

D. Ankle edema is not included as a factor in the Braden Scale assessment.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"D"}}

Explanation

The medical history of the client provides a background of the current issue of concern The nurse describes the current situation that has prompted her to contact the healthcare provider

A recommendation provides a proposal of plan of care to allow the healthcare provider to either agree, disagree or add more insight

A. Positive external place. B. Motivational phrases. C. Emotional reflection. D. Tranquil sounds.

Correct Answer is A

Explanation

A. This technique involves creating vivid mental images of serene and calming environments, allowing the client to mentally escape from discomfort and focus on a peaceful setting. By immersing themselves in this imagined place, clients may experience relaxation and relief from pain.

B. Motivational phrases are statements or affirmations that inspire and encourage the client. While motivational phrases can be incorporated into guided imagery sessions to boost morale and foster positive thinking, they may not be as effective as focusing on a positive external place for managing chronic pain.

C. While emotional reflection can be an important aspect of holistic pain management, it may not be the primary focus during guided imagery sessions aimed at pain relief.

D. While soothing sounds can create a peaceful ambiance and contribute to stress reduction, they are often used as background elements rather than the primary focus of guided imagery for pain management.

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It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

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Naxlex Comprehensive Predictor Exams

Patient Data History and Physical The nurse calls the provider to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"D"}}

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

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The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

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A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?