The nurse uses the Braden scale to assess the client's pressure ulcer risk. Which client score mandates that the nurse implement aggressive prevention measures for pressure ulcers?
1. Less than 13
2. 15 to 18
3. Greater than 18
4. Less than 23
2
2. A Braden scale score less than 13 indicates the client has a high or very high risk for development of a pressure ulcer. These scores are indicative of a client who has impaired sensation, very frequent exposure to moisture, moderate to severe activity impairment, and inadequate nutrition.
1, 3, and 4. Braden scale scores 13 and 14 indicate a moderate risk, scores 15-18 in-dicate a risk, and scores above 20 include clients with the lowest risk for development of pressure ulcers.
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