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.".
"Each element has a range from one to five points.".
"The scale measures six elements.".
"The client's age is part of the measurement.".
The Correct Answer is C
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
“The higher the score, the higher the pressure injury risk”: This statement is incorrect.
The lower the score on the Braden scale, the higher the risk for pressure injury.
“Each element has a range from one to five points”: This statement is incorrect.
Each element has a range from one to four points, except for friction/shear which has a range from one to three points.
“The client’s age is part of the measurement”: This statement is incorrect. Age is not one of the elements measured by the Braden scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
An oral airway can help maintain an open airway during a seizure.
Supplemental oxygen supplies can be used to provide oxygen if the client’s breathing is compromised.
Oral suction equipment can be used to clear secretions from the client’s mouth and prevent aspiration.
Limb restraints: Restraints should not be used during a seizure as they can cause injury.
Blood glucose monitor: While it is important to monitor blood glucose levels in clients with seizures, it is not a priority during a seizure.
Correct Answer is D
Explanation
“Delirium has an abrupt onset.” Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of someone’s surroundings.
The disorder usually comes on fast — within hours or a few days.
Choice A is wrong because delirium does affect a client’s perception of her environment.
Choice B is wrong because delirium does not have a slow progression, but rather an abrupt onset.
Choice C is wrong because delirium can affect a client’s sleep cycle.
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