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Author Question: The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The ... (Read 59 times)

notis

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on: Jul 22, 2018
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
 
  a. 12
  b. 13
  c. 20
  d. 23

Question 2

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?
 
  a. Turn on the television.
  b. Explain the procedure.
  c. Tell the patient Close your eyes.
  d. Ask the family to leave the room.


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dmurph1496

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Reply #1 on: Jul 22, 2018
Answer to Question 1

ANS: D
The best sign is a perfect score of 23. The Braden Scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden Scale in the general adult population is 18.

Answer to Question 2

ANS: B
Explaining the procedure educates the patient regarding the dressing change and involves him in the care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close the eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.


notis

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Reply 2 on: Jul 22, 2018
YES! Correct, THANKS for helping me on my review

scottmt

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Reply 3 on: Yesterday
Excellent

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