The nurse is completing the Braden scale to predict pressure ulcer development risk for a patient on bedrest. Which findings should the nurse score as increasing this patient's risk? (Select all that apply.)
a. Eats half of offered foods
b. Patient responds only to painful stimuli
c. Linen must be changed at least once per shift
d. Makes body position changes with assistance only
e. Walks independently outside of the room twice a day
ANS: A, B, C, D
Findings that would increase the patient's risk of developing a pressure ulcer include limited intake by only eating half of offered foods, responding only to painful stimuli, moisture necessitating linens to be changed at least once per shift, and unable to change body positions without assistance. E. Walking independently outside of the room twice a day would reduce the patient's risk of developing a pressure ulcer.
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