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.

Answer and Explanation

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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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.

A. Teach the client to shorten the stride to prevent falls. B. Record the client's ability to perform ADLs safely. C. Initiate a fall risk protocol for the client. D. Determine the client's activity tolerance.

Correct Answer is B

Explanation

B. Observing the client's upright posture and smooth, steady gait suggests that she is able to ambulate safely without significant risk of falls.

A. This action may be appropriate if the nurse had observed an unsteady or shuffling gait that could increase the risk of falls. However, in this scenario, the nurse has noted that the client's gait is smooth and steady, indicating good balance and stability.

C. The client's upright posture and smooth, steady gait suggest that she has good mobility and balance, which are not indicative of an increased risk of falls.

D. The client's ability to ambulate with an upright posture and smooth, steady gait indicates that she is tolerating activity well. However, the primary focus at this point should be on documenting her functional abilities and assessing her level of independence in performing ADLs safely.

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It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next?

Correct Answer is B

Explanation

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