A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position.

The client's history of integumentary disorders.

The pigmentation of the client's skin.

The client's current medication regimen.

Answer and Explanation

The Correct Answer is A

A. The client's ability to change position is correct. The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Limited mobility increases the risk for pressure injuries.
B. A history of integumentary disorders is not part of the Braden Scale assessment. The scale focuses on current risk factors rather than past dermatologic conditions.
C. Skin pigmentation is not a factor in pressure ulcer risk assessment. However, in clients with darker skin, early signs of pressure injuries may be harder to detect due to lack of visible blanching.
D. Medications are not directly included in the Braden Scale. While some medications (e.g., steroids) can increase pressure injury risk, the Braden Scale does not specifically assess them.

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Correct Answer is B

Explanation

A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.

A. "Do you take painkillers like aspirin on a regular basis?" B. "Are you currently taking vitamin supplements?" C. "Do you tend to eat foods that are quite high in fat?" D. "Do you feel like you're able to accept the stress in your life?"

Correct Answer is A

Explanation

A. Asking about regular painkiller (NSAID) use is correct because nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen are a major risk factor for peptic ulcer disease. They can damage the gastric mucosa and increase acid production, leading to ulcer formation.
B. Vitamin supplements are not a common cause of peptic ulcer disease. While some supplements can cause gastrointestinal discomfort, they are not a primary risk factor.
C. High-fat foods can contribute to acid reflux or indigestion but are not a direct cause of peptic ulcers. Peptic ulcer disease is primarily linked to Helicobacter pylori infection and NSAID use.
D. Stress was once thought to be a major cause of ulcers, but current research indicates that it plays a minor role compared to factors like H. pylori infection and NSAID use.

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A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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