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 A
Explanation
A. Urine culture and sensitivity
Explanation: A urine culture and sensitivity test involves growing bacteria from a urine sample in a laboratory setting. Once the bacteria have grown, they are exposed to different antibiotics to see which one is most effective in inhibiting their growth. This helps healthcare providers identify the specific strain of bacteria causing the infection and choose the most appropriate antibiotic treatment.
B. Serum creatinine level
Explanation: Serum creatinine level is a blood test used to measure kidney function. It evaluates how well the kidneys are filtering waste from the blood. While important for assessing kidney health, it does not determine the specific bacteria causing a urinary tract infection or the appropriate antibiotic treatment.
C. Urinalysis
Explanation: Urinalysis is a broad screening test that assesses various components in the urine, such as red and white blood cells, protein, glucose, and bacteria. While it can detect signs of a urinary tract infection (such as the presence of bacteria and white blood cells), it does not identify the specific bacterial strain causing the infection or provide information about antibiotic sensitivity.
D. Kidney scan
Explanation: A kidney scan, also known as a renal scan, is a medical imaging technique used to assess the structure and function of the kidneys. It can help diagnose conditions like kidney stones, urinary obstruction, or kidney infections. However, it does not determine the strain of bacteria causing a urinary tract infection or guide antibiotic treatment.
Correct Answer is D
Explanation
A. "I will reduce my intake of sodium." - This statement is correct. High sodium intake can lead to increased calcium excretion through the urine, which can weaken bones. Reducing sodium intake can help prevent osteoporosis.
B. "I will limit my intake of soft drinks." - This statement is correct. Soft drinks, especially cola beverages, contain phosphoric acid, which can leach calcium from bones, leading to decreased bone density. Limiting soft drink consumption is advisable for bone health.
C. "I will decrease my intake of caffeine." - This statement is correct. Excessive caffeine consumption can interfere with calcium absorption and increase calcium excretion. It is advisable to limit caffeine intake to prevent osteoporosis.
D. "I will reduce my intake of vitamin K-rich foods." - This statement is incorrect. Vitamin K is essential for bone health as it helps in bone mineralization and reduces the risk of fractures. Foods rich in vitamin K, such as leafy green vegetables, are beneficial for bone health and should not be reduced unless there are specific medical reasons to do so.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today