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."
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Exercise 1 hr before bedtime:
While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day
B. Drink a cup of hot cocoa before bedtime:
While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime: can help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep
.
D. Take a 30-min nap daily:
Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.
Correct Answer is D
Explanation
A. Elevate full-length side rails on both sides of the client's bed:
While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.
B. Place the bedside table 0.9 m (3 feet) away from the bed:
Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.
C. Keep the client's room temperature at 18°C (64.4°F):
While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.
D. Provide the client with a night light:
This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.
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