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."

Answer and Explanation

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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Correct Answer is C

Explanation

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

A. Respiratory rate B. Weight C. Level of orientation D. Current pain level

Correct Answer is B

Explanation

A. Respiratory rate is part of vital signs assessment but is not typically included in anthropometric measurements.
B. Weight is a key component of anthropometric assessment, measuring body mass or body weight.
C. Level of orientation pertains to the client's mental status and cognitive functioning, not part of anthropometric measurements.
D. Current pain level is important but not directly related to anthropometric measurements.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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