A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
"Each element has a range from one to five points."
"The client's age is part of the measurement."
"The higher the score, the higher the pressure injury risk
The scale measures six elements
The Correct Answer is D
The Braden scale is a commonly used tool for assessing a patient's risk of developing pressure injuries (also known as pressure ulcers or bedsores). It evaluates six specific elements to determine the patient's risk level. These elements include sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element is assessed and assigned a score, with a lower score indicating a higher risk for developing pressure injuries.
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Related Questions
Correct Answer is A
Explanation
Delirium is an acute confusional state that develops rapidly over a short period of time, often within hours or days. It is characterized by a disturbance in consciousness and attention, along with changes in cognition and perception.
Delirium can significantly impact a client's perception of their environment. Clients with delirium may experience hallucinations, delusions, and misinterpretations of their surroundings. They may become disoriented, have difficulty recognizing familiar people or places, and exhibit altered levels of awareness and attention.
As mentioned earlier, delirium has an abrupt onset, meaning it develops rapidly. Delirium is usually a transient condition that fluctuates throughout the day, with symptoms varying in severity.
Delirium can disrupt a client's sleep-wake cycle. Clients with delirium may experience disturbances in their sleep patterns, such as difficulty falling asleep, frequent awakening during the night, or excessive sleepiness during the day.
Correct Answer is A
Explanation
Assistive personnel can provide valuable assistance in ambulating clients who have mobility limitations. Assisting a client with ambulation involves helping them move and walk safely, which can aid in improving their lung function and overall pulmonary status. This task typically does not require specialized medical training and can be safely delegated to assistive personnel. Inserting a glycerin suppository for a constipated client requires knowledge of proper insertion technique, potential complications, and the ability to assess the client's response to the intervention. This task is typically performed by licensed nurses.
Irrigating a client's infected surgical wound involves an aseptic technique, knowledge of wound care principles, and the ability to assess the wound for signs of infection or complications. This task is typically performed by licensed nurses or wound care specialists.
Showing a client how to use an incentive spirometer prior to surgery requires knowledge of respiratory physiology, proper technique, and the ability to assess and instruct the client effectively. This task is typically performed by licensed nurses or respiratory therapists.
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