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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Correct Answer is D
Explanation
A. Two-point alternating gait involves partial weight-bearing on both legs and wouldn’t suit a client who can bear weight on only one leg.
B. Four-point alternating gait involves walking by moving one crutch followed by the opposite leg and is not suitable for a person who can bear weight on just one leg.
C. Swing-through gait involves swinging both legs forward between the crutches, typically used for individuals who have little or no weight-bearing ability.
D. Three-point gait involves bearing weight on one leg while using crutches and moving the other leg forward, the most appropriate gait for someone who can bear weight on one leg.
Correct Answer is C
Explanation
A. Stating that hospice care is the best option might not align with the client's wishes for continued treatment.
B. Encouraging the client to enjoy their time is supportive but doesn't address the client's request for more treatment.
C. Initiating a discussion with the healthcare provider allows the client to explore available treatment options while honoring their wishes.
D. Using phrases that emphasize the limited time left might not be supportive or respectful of the client's wishes for more treatment.
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