On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.)
a. Mobility
b. Nutrition
c. Infection
d. Friction and shear
e. Sensory perception
A, B, D, E
The Braden Scale is a highly reliable scale that uses six subscales to identify patients at greatest risk for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Infection is not an area that is assessed on the Braden Scale.
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A patient presents to the walk-in clinic complaining of vomiting and burning in his mid-epigastria. The nurse knows that to confirm peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?
A) Infection with Helicobacter pylori B) Excessive stomach acid secretion C) Gastric irritation caused by nonsteroidal anti-inflammatory drugs (NSAIDs) D) Inadequate production of pancreatic enzymes
The nurse would like to ensure that a cancer client receives the maximum benefit from music being played in the client's room. According to research, which intervention should the nurse plan?
1. Use music popular in the happiest years of the client's life. 2. Play classical music quietly in the background. 3. Plan time for the nurse to stay with the client while the music is played. 4. Play only music that has a positive, uplifting message.
A multigravida is admitted to the hospital in active labor. The patient's and the fetus's condition have been good since admission. The patient suddenly calls out to the nurse, "the baby is coming!" What should the nurse do first?
A) Time the contractions B) Auscultate the fetal heart tones C) Contact the physician D) Inspect the perineum
One component of a community hospital's current evidence-based practice (EBP) initiative is the establishment of an onsite journal club for nurses. Which of the following individuals would be the best candidate to lead the club?
A) A member of another health discipline who has led such groups before B) An advanced practice nurse who is familiar with research C) A nursing professor from a local university who has performed research D) A staff nurse who is experienced and well-regarded by colleagues