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?
"The scale measures six elements."
"The client's age is part of the measurement."
"The higher the score, the higher the pressure injury risk."
"Each element has a range from one to five points."
The Correct Answer is A
A. The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B. The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C. In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D. Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.
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Related Questions
Correct Answer is C
Explanation
A. Weighing oneself once weekly may not be frequent enough to monitor changes related to heart failure or medication effects.
B. Taking hydrochlorothiazide in the evening is not usually a crucial safety consideration; it is typically taken in the morning due to its diuretic effects.
C. Leaving a light on in the bathroom at night can prevent falls, which are a significant concern in older adults with heart failure.
D. Taking a hot bath before bedtime might not be a safety consideration related to heart failure or medication use and could potentially cause issues with temperature regulation or dehydration.
Correct Answer is A
Explanation
Rationale for A: Area rugs pose a significant tripping hazard for older adults, especially for those with osteoporosis who are at an increased risk for fractures if they fall. The nurse should intervene by advising the client to remove the area rug to prevent falls.
Rationale for B: Grab bars installed in the shower are a safety feature that helps prevent falls, especially for clients with mobility issues. This is a positive finding and does not require intervention.
Rationale for C: Storing prescriptions in a medication organizer helps the client keep track of their medications and prevents confusion, especially in older adults. This is an effective way to manage medications and does not need intervention.
Rationale for D: The hot water heater set to 47°C (117°F) is within the safe range to prevent burns while still providing sufficient warmth for bathing. This does not pose a risk to the client, and no intervention is needed.
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