A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?
Morse Scale
Braden Scale
Bristol Scale
Hendrich II scale
The Correct Answer is B
A. Morse Scale:
The Morse Scale, also known as the Morse Fall Scale, is used to assess a patient's risk of falling. It evaluates various factors such as history of falling, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status. It is primarily focused on assessing the risk of falls, not pressure ulcers.
B. Braden Scale:
As previously mentioned, the Braden Scale assesses a patient's risk for developing pressure ulcers. It takes into account sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The scale helps healthcare providers determine the level of risk a patient has for developing pressure sores and guides interventions to prevent them.
C. Bristol Scale:
The Bristol Stool Scale is used to classify the form of human feces into seven categories. It is a medical aid designed to classify the form of human feces into seven categories. This scale is primarily used to assess bowel movements and is unrelated to pressure ulcers.
D. Hendrich II Scale:
The Hendrich II Fall Risk Model is a tool designed to identify patients at risk for falls. It includes factors such as confusion, symptomatic depression, altered elimination, dizziness, male gender, and the use of antiepileptics, benzodiazepines, or non-opioid analgesics. Similar to the Morse Scale, it focuses on assessing the risk of falls, not pressure ulcers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Malunion: Malunion happens when a fractured bone heals in an improper position, leading to deformity and functional impairment. While it is a concern, it typically develops over time during the healing process and is not an immediate early complication that the nurse would monitor for in the acute phase following a fracture.
B. Compartment syndrome: Compartment syndrome is a serious condition that can occur after an injury, such as a fracture. When there is increased pressure within a muscle compartment, it can lead to reduced blood flow, potentially causing tissue damage and nerve injury. Prompt recognition and intervention are crucial to prevent complications.
C. Fat embolism: Fat embolism occurs when fat particles from the bone marrow or other sources enter the bloodstream, often after a long bone fracture or major trauma. These particles can travel to the lungs and other organs, causing respiratory distress, confusion, and other symptoms. Fat embolism is a significant concern in orthopedic trauma patients and requires careful monitoring.
D. Deep vein thrombosis (DVT): DVT is the formation of blood clots in deep veins, usually in the legs. Patients with fractures, especially those immobilized for extended periods, are at increased risk for DVT. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, which is a life-threatening complication.
E. Pulmonary emboli: Pulmonary emboli occur when blood clots, often originating from DVT, travel to the lungs and block pulmonary arteries. This condition can lead to sudden difficulty breathing, chest pain, and even cardiac arrest. Pulmonary embolism is a medical emergency and requires immediate intervention.
Correct Answer is D
Explanation
A. Void every 6 to 8 hours:This interval may not be frequent enough. It is generally recommended to void every 2 to 3 hours to help flush out bacteria and reduce the risk of infection.
B. Avoid voiding immediately after sexual intercourse.This is not recommended. It is actually advised to void immediately after sexual intercourse to help flush out any bacteria that may have entered the urethra.
C. Take a bubble bath daily and keep the perineal region clean:
While keeping the perineal region clean is important for general hygiene, taking bubble baths and using heavily scented products can irritate the urethra and potentially increase the risk of UTIs. The nurse should advise against frequent bubble baths and suggest using mild, unscented soaps for the perineal area.
D. Increase the daily amount of water consumed:
Drinking more water helps increase urine output, which helps flush out bacteria from the urinary tract and can reduce the risk of recurrent UTIs.
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