The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)
Sensory perception
Age
Friction and shear
Nutrition
Mental state
Correct Answer : A,C,D
Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.
Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.
Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.
Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
Choice A reason: This is the correct statement because it reflects the fact that reexposure to HIV can increase the viral load and accelerate the decline of the immune system. HIV is a virus that infects and destroys the CD4 cells, which are the white blood cells that help fight infections. AIDS is the final stage of HIV infection, when the CD4 count falls below 200 cells/mm3 or the client develops an opportunistic infection. The progression from HIV to AIDS can vary from person to person, depending on several factors, such as viral strain, genetic factors, treatment adherence, and coinfections. Reexposure to HIV can expose the client to a different or more aggressive strain of the virus, which can overwhelm the immune system and hasten the development of AIDS.
Choice B reason: This is an incorrect statement because it ignores the role of nutrition in maintaining the health and function of the immune system. Diet can influence the progression of HIV to AIDS by affecting the client's weight, energy, metabolism, and susceptibility to infections. The client should eat a balanced and varied diet that provides adequate calories, protein, vitamins, minerals, and fluids. The client should also avoid foods that can cause diarrhea, dehydration, or food poisoning, which can worsen the symptoms and complications of HIV infection.
Choice C reason: This is an incorrect statement because it contradicts the evidence that shows that meditation can have positive effects on the psychological and physiological wellbeing of people living with HIV. Meditation is a mindbody practice that involves focusing attention on the present moment, breathing, and relaxation. Meditation can help the client cope with stress, anxiety, depression, and pain, which are common challenges for people living with HIV. Meditation can also improve the immune system function by reducing inflammation, oxidative stress, and cortisol levels, which can slow down the progression of HIV to AIDS.
Choice D reason: This is an incorrect statement because it overlooks the impact of sexually transmitted infections (STIs) on the course of HIV infection. STIs can increase the risk of transmitting and acquiring HIV by causing ulcers, inflammation, or bleeding in the genital area, which can facilitate the entry and exit of the virus. STIs can also increase the viral load and decrease the CD4 count, which can speed up the progression of HIV to AIDS. The client should practice safe sex by using condoms, getting tested and treated for STIs, and informing their sexual partners about their HIV status.
Correct Answer is B
Explanation
Choice A reason: Providing the client with antipyretic therapy is not the nurse's priority. Antipyretic therapy is a treatment that lowers the body temperature and reduces fever. Fever is a common symptom of acute osteomyelitis, which is a bacterial infection of the bone and bone marrow. Antipyretic therapy may help to relieve the discomfort and inflammation caused by fever, but it does not address the underlying cause of the infection.
Choice B reason: Administering antibiotics to the client is the nurse's priority. Antibiotics are medications that kill or inhibit the growth of bacteria. Antibiotics are the main treatment for acute osteomyelitis, as they target the specific type of bacteria that is causing the infection. Antibiotics can prevent the spread of the infection to other bones or organs and reduce the risk of complications, such as chronic osteomyelitis, septic arthritis, or sepsis.
Choice C reason: Increasing the client's protein intake is not the nurse's priority. Protein intake is a nutritional factor that affects the wound healing and immune system. Protein is composed of amino acids, which are the building blocks of cells and tissues. Protein intake can enhance the repair and regeneration of the bone and the soft tissues that are damaged by the infection. Protein intake can also support the immune system's ability to fight off the infection. However, protein intake alone is not sufficient to treat acute osteomyelitis, as it does not eliminate the bacteria that are causing the infection.
Choice D reason: Teaching relaxation breathing to reduce the client's pain is not the nurse's priority. Relaxation breathing is a technique that involves deep and slow breathing that helps to relax the body and mind. Relaxation breathing can help to reduce the pain and stress that are associated with acute osteomyelitis. Pain is a common symptom of acute osteomyelitis, which is caused by the inflammation and pressure on the bone and the surrounding tissues. Relaxation breathing can help to ease the pain and improve the mood and quality of life of the client. However, relaxation breathing alone is not enough to treat acute osteomyelitis, as it does not address the source of the pain.
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