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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Related Questions
Correct Answer is D
Explanation
D. Neuropathy, especially when associated with numbness and tingling in the lower extremities, poses a significant risk for impaired skin integrity. The loss of sensation can lead to decreased awareness of pressure, friction, or trauma to the feet, making the client more susceptible to skin breakdown, ulcers, and injuries.
A. Increasing numbness and tingling in the lower extremities, which primarily suggests neuropathic symptoms rather than impaired mobility.
B. A self-care deficit may arise if the client's neuropathy significantly affects their ability to perform foot care tasks independently. However, self-care deficit becomes a priority concern.
C. Neuropathy can increase the risk of foot injuries due to decreased sensation, which in turn can lead to infections if not promptly addressed. However, while infection is a potential complication, the immediate concern in this scenario is preventing the development of skin breakdown and ulcers.
Correct Answer is C
Explanation
A. Administering pain medication solely based on nonverbal cues without further assessment and confirmation of pain may lead to unnecessary medication administration and potential adverse effects.
B.Monitoring the client's nonverbal behavior is crucial in this situation because it can provide valuable insight into the client's pain experience. However, this shoudl come after listening to the client first.
C. Directly asking the client about the grimacing is a very reasonable approach. Since the client denies pain but is exhibiting nonverbal signs of discomfort, the nurse could ask specific questions to explore whether there is another underlying cause.
D. Reviewing the pain medications prescribed is important to ensure that the client is receiving appropriate pain management, but it may not be the most immediate intervention in this scenario.
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