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?

Choice A reason:

Chewing sublingual medication is inappropriate as it is designed to dissolve under the tongue for rapid absorption into the bloodstream. Chewing it would alter the intended administration route and reduce its effectiveness.

Choice B reason:

Allowing the medication to dissolve completely under the tongue is correct and ensures that it is absorbed quickly into the bloodstream. This method allows the active ingredient to bypass the digestive system and liver, providing faster therapeutic effects.

Choice C reason:

While it is essential to follow any specific dietary instructions for medications, drinking juice or water typically does not interfere with sublingual medications. This statement does not accurately reflect the correct administration technique.

Choice D reason:

Placing sublingual medication between the cheek and gum is incorrect as this method is intended for buccal medications, not sublingual ones. Sublingual medications should be placed under the tongue to dissolve properly.

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.