The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital?

Monitor the Glasgow Coma Scale.

Complete the Braden Scale.

Initiate a Brudzinski flow sheet.

Assess for Babinski's sign.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.

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Correct Answer is C

Explanation

Choice A reason: A WBC count of 8,000/mm³ falls within the normal range (4,000-11,000/mm³) and does not indicate a specific risk for delayed wound healing. It helps assess the immune response but is not a direct marker for nutrition or tissue repair.

Choice B reason: A hemoglobin level of 16 g/dL is within the normal range (13.8-17.2 g/dL for men, 12.1-15.1 g/dL for women) and indicates adequate oxygen-carrying capacity. While essential for overall health, it does not directly correlate with the risk of delayed wound healing in this context.

Choice C reason: This is the correct answer. Serum albumin levels are a marker of nutritional status. A level of 3.2 g/dL is on the lower side of the normal range (3.5-5.0 g/dL) and indicates potential malnutrition, which can impair wound healing by limiting the availability of necessary proteins and nutrients for tissue repair.

Choice D reason: An INR (International Normalized Ratio) of 0.9 is within the normal range (0.8-1.2) and reflects normal blood clotting. While important for understanding coagulation status, it does not indicate a direct risk for delayed wound healing related to nutrition or protein levels.

A. Vegetables B. Smoked sausage C. Chicken D. Cherries

Correct Answer is B

Explanation

Choice A reason:

Vegetables are generally safe and are not typically restricted in the diet of a client taking an MAOI. They do not contain high levels of tyramine, which can interact adversely with MAOIs.

Choice B reason:

Smoked sausage should be eliminated from the diet as it contains high levels of tyramine. Consuming tyramine-rich foods while taking MAOIs can lead to hypertensive crises, making it essential to avoid such foods.

Choice C reason:

Chicken is a safe protein choice and does not need to be eliminated from the diet of a client on an MAOI. It does not pose a risk of high tyramine levels.

Choice D reason:

Cherries are safe to consume and do not contain high levels of tyramine, so they do not need to be restricted in the diet of a client taking an MAOI.

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The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital?

Nursing Test Bank

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