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 D
Explanation
A. Reads and follows the health care provider's orders. While following provider orders is important, critical thinking requires assessing the situation and considering all relevant factors, rather than just following orders without analysis.
B. Accepts one established way to provide care. Critical thinking involves evaluating different approaches and adapting to individual patient needs rather than rigidly adhering to a single method.
C. Makes decisions based on intuition. While intuition can be helpful, evidence-based practice and clinical reasoning should guide decision-making, not just intuition alone.
D. Consider what is important in any given situation. Critical thinking involves analyzing the situation, prioritizing information, and making decisions based on what is most important for patient safety and care.
Correct Answer is D
Explanation
- 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.
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