The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shearing. Which score will the nurse document for this patient?
23
15
17
20
The Correct Answer is D
- Sensory perception: Slightly limited (score of 3)
- Moisture: Rarely moist (score of 4)
- Activity: Walks occasionally (score of 3)
- Mobility: Slightly limited (score of 3)
- Nutrition: Excellent intake (score of 4)
- Friction and shear: No apparent problem (score of 3)
Adding these scores together: 3 + 4 + 3 + 3 + 4 + 3 = 20
Therefore, the nurse should document a score of 20 for this patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air).
B. Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms.
C. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles.
D. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.
Correct Answer is C
Explanation
A. 4, 3, 2, 1 (Pulmonic → Tricuspid → Aortic → Mitral): This sequence incorrectly places the pulmonic valve first instead of the tricuspid.
B. 1, 3, 2, 4 (Mitral → Tricuspid → Aortic → Pulmonic): This sequence incorrectly starts with the mitral valve (left side of the heart), instead of the tricuspid (right side of the heart).
C. 3, 4, 1, 2 (Tricuspid → Pulmonic → Mitral → Aortic): Blood flow through heart valves follows this order:
- Tricuspid Valve (Right atrium → Right ventricle)
- Pulmonic Valve (Right ventricle → Pulmonary artery → Lungs)
- Mitral Valve (Left atrium → Left ventricle)
- Aortic Valve (Left ventricle → Aorta → Body)
D. 2, 4, 1, 3 (Aortic → Pulmonic → Mitral → Tricuspid): This sequence incorrectly places the aortic valve first, which is incorrect for blood flow through the heart.
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