The nurse uses the Braden scale to assess the patient's pressure ulcer risk. Which patient score mandates that the nurse implement aggressive prevention measures because of being at high risk for skin breakdown?
a. Less than 9
b. 15 to 18
c. 19
d. 23
A
A Braden scale score less than 9 indicates that the patient has a very high risk for development of a pressure ulcer. These scores are indicative of a patient who has impaired sensation, very fre-quent exposure to moisture, moderate-to-severe activity impairment, and inadequate nutrition. Braden scale scores 13 and 14 indicate a moderate risk, scores 15 to 18 indicate a mild risk, and a score above 19 includes patients with the lowest risk for development of pressure ulcers. A pa-tient with a score of 23 has no risk of skin breakdown.
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