A wound has a bloodtinged liquid that is dripping from the surgical site. How does the nurse document this finding?

Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.

Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.

Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.

Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.

Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.

Choice A reason: Joint pain with swelling is the correct answer, because it is a common symptom of SLE. SLE is a chronic autoimmune disease that causes inflammation and damage to various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Joint pain with swelling is caused by the inflammation of the synovial membrane that lines the joints, which can lead to stiffness, reduced mobility, and deformity.

Choice B reason: Intense wrinkles is not the correct answer, because it is not a symptom of SLE. Intense wrinkles are a cosmetic issue that affects the appearance of the skin, not the function of the organs or tissues. Intense wrinkles are caused by the loss of collagen and elasticity in the skin, which can result from aging, sun exposure, smoking, or dehydration.

Choice C reason: Raynaud's phenomenon is not the correct answer, because it is not a symptom of SLE. Raynaud's phenomenon is a condition that affects the blood flow to the fingers and toes, not the joints or other organs. Raynaud's phenomenon is caused by the narrowing of the small arteries that supply blood to the extremities, which can result from cold, stress, or other factors.

Choice D reason: Tachycardia is not the correct answer, because it is not a symptom of SLE. Tachycardia is a condition that affects the heart rate, not the joints or other organs. Tachycardia is caused by the abnormal electrical activity of the heart, which can result from anxiety, fever, infection, or other causes.