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. Client educator: Involves imparting knowledge or information to the client or others, which isn't the primary role of the nurse manager in this scenario.
B. Client advocate: Represents and supports the client's rights and needs.
C. Client care provider: The nurse manager is ensuring proper care provision by overseeing the procedure directly.
D. Case manager: Coordinates care and resources for the client's overall plan but isn't directly involved in overseeing a specific procedure.
Correct Answer is B
Explanation
A. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces on the skin.
B. Elevating the heels reduces the pressure on the skin and improves blood circulation.
C. Raising the head of the bed to a 60° angle doesn't directly address pressure injury prevention and might even increase pressure on certain areas.
D. Repositioning the client every 4 hours is not frequent enough to prevent pressure injuries.
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