What level of Braden Scale score indicates a high risk for developing pressure ulcers, requiring immediate intervention?
A score of 10 to 12.
A score of 15 to 18.
A score of 19 to 23.
A score of 24 to 30.
The Correct Answer is A
Choice A rationale
On the Braden Scale, a total score of 10 to 12 represents a high risk for the development of pressure injuries. This scale assesses six subscales including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A lower score indicates a higher risk. At this level, aggressive preventive interventions are required immediately, such as frequent repositioning every two hours, using pressure-redistributing surfaces, and optimizing nutritional intake to protect the integrity of the skin and underlying tissues.
Choice B rationale
A Braden Scale score ranging from 15 to 18 is categorized as a mild risk for pressure injury development. While this score still necessitates some preventive measures, such as turning schedules and moisture management, it does not represent the high-risk category that requires the most intensive level of intervention. The nurse should still monitor the patient closely, but the urgency is lower than for a patient scoring in the 10 to 12 range or below.
Choice C rationale
Scores between 19 and 23 on the Braden Scale indicate that the patient is at a very low risk or is generally not at risk for developing pressure injuries. Patients in this range typically have good mobility, adequate nutrition, and intact sensory perception. While routine skin care and assessment remain part of standard nursing practice, specialized pressure-relief protocols are generally not indicated for this group unless their clinical status changes significantly or their mobility becomes suddenly impaired.
Choice D rationale
A score of 24 to 30 is not possible on the standard Braden Scale, as the maximum score is 23. The scale evaluates six categories with most having a maximum of 4 points and one having a maximum of 3 points. Therefore, any score above 23 is mathematically impossible. When using this assessment tool, nurses must be familiar with the correct scoring range to accurately identify patient risk and implement the appropriate evidence-based interventions for skin protection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Peripheral nerve damage and inflammatory responses at the surgical site do contribute to the complex nature of post-amputation sensations, but they are not the sole scientific cause of phantom limb sensation. PLS involves a much more intricate neurological process within the central nervous system. Focusing only on local irritation or swelling fails to account for the cortical reorganization that occurs in the brain following the loss of input from the removed anatomical structure.
Choice B rationale
The theory that phantom limb sensation is caused by continued bone growth or tissue damage is scientifically inaccurate. While pediatric patients may experience terminal overgrowth of the residual bone, which can cause localized pain and require revision surgery, this is a distinct clinical entity from PLS. Phantom sensations are primarily a result of the brain's neuroplasticity and the continued activity of the somatosensory cortex that previously mapped the sensory input from the missing limb.
Choice C rationale
This statement accurately describes the physiological phenomenon where the brain continues to receive and interpret signals as if the limb were still attached. The somatosensory cortex maintains a map of the body, and when a limb is removed, the neurons previously responsible for that limb may fire spontaneously or be stimulated by adjacent areas. This neural activity creates a vivid, real perception of the limb's presence, position, or movement despite its physical absence from the body.
Choice D rationale
Phantom limb sensation is actually less common in children with congenital limb deficiencies compared to those who undergo traumatic amputations. For PLS to occur, the brain must have established a functional sensory map of the limb through prior experience and usage. Children born without a limb have not developed the same cortical representation, so they are significantly less likely to experience the sensation of a missing part compared to a child who loses a developed limb.
Correct Answer is A
Explanation
Choice A rationale
Gasoline is a liquid hydrocarbon that can continue to damage the skin and be absorbed systemically if not removed immediately. Decontamination is the priority to stop the burning process and prevent further chemical injury to the client and exposure to healthcare staff. It involves removing saturated clothing and flushing the skin with water. This essential safety step must occur before other assessments or interventions to ensure the clinical environment remains safe for everyone.
Choice B rationale
Asking about the last meal is part of a secondary assessment, specifically for potential surgical intervention or intubation risks. While important for general anesthesia preparation, it does not address the immediate life safety threat posed by chemical contaminants on the body. In the hierarchy of trauma care, stopping the injury source through decontamination precedes gathering nutritional history. This information is valuable for preventing aspiration during later procedures but is not the primary safety concern.
Choice C rationale
Elevating the head of the bed is a standard intervention to reduce edema and improve respiratory excursion, especially in burn patients. However, this action is subordinate to the immediate need for decontamination in a chemical burn scenario. Respiratory support and positioning are part of the ABCs, but if the patient is still covered in gasoline, the chemical continues to destroy tissue. Decontamination is the unique priority here to stabilize the wound environment and prevent inhalation of fumes.
Choice D rationale
Determining the exact volume of gasoline encountered provides context for the severity of exposure but does not mitigate the current physical risk. While toxicological data is helpful for long term management, the immediate physical presence of the chemical on the skin is the emergency that requires action. Knowing the amount does not change the initial requirement for thorough irrigation and removal of the substance. Treatment focuses on clinical presentation and immediate neutralization of the causative agent.
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