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 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.

A. Provide comfort measures such as topical warm application and tactile massage. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Determine client's subjective-measure of pain using a numerical pain scale.

Correct Answer is ["A","B","E"]

Explanation

A. Provide comfort measures such as topical warm application and tactile massage. Comfort measures can help alleviate chronic pain symptoms and provide relief to the client.

B. Implement a 24-hour schedule of routine administration of prescribed analgesic. Consistent administration of prescribed analgesics helps maintain pain control and manage chronic pain effectively.

E. Determine the client's subjective measure of pain using a numerical pain scale. Assessing the client's pain using a numerical pain scale allows for quantification of pain intensity, which helps guide pain management interventions and evaluate effectiveness.

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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

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

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