The nurse is assessing the client for pressure ulcer risk. The client has no sensory deficits, and the skin is dry and not exposed to moisture. The client is, however, confined to bed and is completely immobile and requires moderate assistance in moving
The client's nutritional status is adequate. Which score documented by the nurse is the most appropriate based on the assessment data?
1. 14, indicating moderate risk
2. 15, indicating high risk
3. 12, indicating risk
4. 14, indicating high risk
Correct Answer: 1
The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 point for shear related to needing moderate assistance to move, totaling 14. A score of 15-18 indicates some risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate risk.
You might also like to view...
Which of the following should be included in the nurse's preadministration assessment prior to administering a penicillin to a client? Select all that apply
A) Allergy history B) Medical history C) Medication history D) Blood glucose levels E) Current symptoms
A staff nurse with a bachelor's degree has decided to concentrate on nursing research, as the nurse believes that research can greatly improve client outcomes. Which is true of the nurse with a bachelor's degree in regards to nursing research?
Select all that apply. A) Can identify areas of need for nursing research B) Is not expected to participate in research until pursuing a higher degree C) Can incorporate research results in client care D) Can participate in research as the principal investigator E) Can participate in nursing research projects
The client is displaying behaviors that indicate to the nurse that she is in the "taking-in" phase. Which intervention would be most appropriate to integrate into the client's care at this time?
a. Counseling about parental role transitions b. Planned undisturbed periods of rest and sleep c. Return demonstration of a baby bath d. Teaching contraceptive options
At her first prenatal visit, a woman is discussing fetal development with the nurse. The patient asks, "When will my baby actually have a heartbeat?" The nurse should reply, "The heartbeat of an embryo is distinguishable by:
1. "The fourth week.". 2. "The sixth week.". 3. "The eighth week.". 4. "The twelfth week.".