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 higher the score, the higher the pressure injury risk."

The client's age is part of the measurement."

"Each element has a range from one to five points."

"The scale measures six elements."

Answer and Explanation

The Correct Answer is D

A. "The higher the score, the higher the pressure injury risk.": The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.

B. "The client's age is part of the measurement.": The client’s age is not a direct factor measured by the Braden Scale.

C. "Each element has a range from one to five points.": Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.

D. "The scale measures six elements.":

The Braden Scale evaluates six elements: Sensory perception, Moisture, Activity, Mobility, Nutrition and Friction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.

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Correct Answer is ["A","B","C"]

Explanation

A. Cholesterol level: Elevated cholesterol levels are a risk factor for heart disease. High levels of low-density lipoprotein (LDL) cholesterol and low levels of high-density lipoprotein (HDL) cholesterol are associated with an increased risk of cardiovascular disease.

B. History of hyperlipidemia: Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, including cholesterol and triglycerides. A history of hyperlipidemia indicates a pre-existing condition that can contribute to the risk of heart disease.

C. History of hypertension: Hypertension (high blood pressure) is a significant risk factor for heart disease. It can lead to damage to the arteries, increasing the risk of atherosclerosis (narrowing and hardening of the arteries) and other cardiovascular complications.

Explanation:

D. History of rheumatoid arthritis: While rheumatoid arthritis is an autoimmune condition that primarily affects the joints, it is not a direct risk factor for heart disease. However, people with rheumatoid arthritis may have an increased risk of cardiovascular disease due to inflammation.

E. Fasting glucose level: The fasting glucose level is related to diabetes rather than heart disease. However, diabetes is a significant risk factor for heart disease, so managing glucose levels is crucial for overall cardiovascular health.

F. Family history: While a family history of heart disease can contribute to an individual's overall risk, it is not a direct finding in the medical record that places the client at risk. The specific risk factors mentioned earlier (cholesterol level, history of hyperlipidemia, and history of hypertension) are more direct indicators of cardiovascular risk.

A. Ask the family if they wish to assist in washing the client's body. B. Turn overhead lights to a bright setting. C. Leave the client's eyes open until the family views the body. D. Remove the client's dentures for their family to keep.

Correct Answer is A

Explanation

A. Ask the family if they wish to assist in washing the client's body:

This is an appropriate action. Providing an opportunity for the family to participate in postmortem care can be a culturally sensitive and therapeutic approach. It allows the family to be involved in a meaningful way and may contribute to the grieving process.

B. Turn overhead lights to a bright setting:

This is incorrect. The environment for postmortem care should be handled with respect and consideration for the family. Turning the lights to a bright setting may create an uncomfortable or clinical atmosphere. A calm and serene environment is more appropriate for this sensitive task.

C. Leave the client's eyes open until the family views the body:

This is incorrect. It is customary to gently close the deceased person's eyes as part of postmortem care. Leaving the eyes open may be distressing for the family and does not contribute to creating a peaceful appearance.

D. Remove the client's dentures for their family to keep:

This is incorrect. Dentures are typically returned to the family rather than kept by the family. The nurse should handle the removal of any personal items with sensitivity and respect, returning them to the family as appropriate.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is preparing to provide postmortem care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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