It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?
Weakened cough effort.
Hypoactive bowel sounds.
Urinary incontinence.
Plus two ankle edema.
The Correct Answer is C
C. Urinary incontinence affects the moisture component of the Braden scale. Proper assessment and interventions are crucial to prevent skin breakdown.
A. A weakened cough effort is not directly related to pressure ulcer risk assessment, which is the purpose of the Braden Scale.
B. Bowel sounds are not included in the Braden Scale assessment criteria.
D. Ankle edema is not included as a factor in the Braden Scale assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Delayed or inability to void after catheter removal could indicate urinary retention, which may require further intervention such as bladder scanning, straight catheterization, or reinsertion of a urinary catheter.
B. This is important for assessing the timing of antibiotic therapy but may not be directly related to the client's ability to void after catheter removal.
C. Color of the urine during catheter removal may provide information about the client's urinary status, but it does not confirm whether the client was able to void effectively after catheter removal.
D. Intake and output reports for the previous shift is relevant for assessing fluid balance and urinary output trends but does not specifically address the client's ability to void after catheter removal.
Correct Answer is B
Explanation
B. This timing is based on the gastrocolic reflex, which typically triggers bowel movements shortly after eating. By assisting the client to the commode after meals, the nurse can take advantage of this reflex and increase the likelihood of successful bowel evacuation, reducing the risk of fecal incontinence episodes.
A. Incontinence briefs can provide containment for fecal incontinence and help manage soiling of clothing and bedding. However, they do not address the underlying issue of fecal incontinence or contribute to bowel training.
C. Administering a glycerin suppository after meals may stimulate bowel movements, but it does not address the underlying causes of fecal incontinence or promote bowel training.
D. Inserting a rectal tube at specified intervals may be indicated for fecal management in certain clinical situations, but it is not typically used as a primary intervention for bowel training in clients with chronic fecal incontinence.
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