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?
Each element has a range from one to five points.
The higher the score, the higher the pressure injury risk.
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. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.
Option a is incorrect because each element has a range from one to four points.
Option b is incorrect because the lower the score, the higher the pressure injury risk.
Option d is incorrect because the client's age is not part of the measurement.
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Correct Answer is A
Explanation
Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.
Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many different conditions, including fatigue or depression. Increased reflexes and increased auditory alertness are not commonly associated with sleep deprivation.
Correct Answer is A
Explanation
When providing change-of-shift report about a client who has shingles, the nurse should include information about the type of transmission-based precautions in place to prevent the spread of infection to other clients and staff. Shingles is caused by the varicella-zoster virus and can be spread through direct contact with the rash.
- The times for routine vital sign measurements may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The client's background health history may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The number of visitors the client had during the shift may be important information to include in the report, but it is not specific to the client's condition of shingles.
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