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?

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Quizplus · Accepted Answer

The Braden Scale is commonly used to assess pressure ulcer risk. Based on the assessment data provided, the client has no sensory deficits and adequate nutritional status, which are protective factors against pressure ulcers. However, the client is completely immobile and requires moderate assistance in moving, which puts the client at risk for pressure ulcers. The score of 14 on the Braden Scale indicates moderate risk. A score of 15 or less is considered high risk, but based on the assessment data, the client's score is 14, indicating moderate risk. A score of 12 or less is indicative of significant risk for pressure ulcers.

The Nurse Is Assessing the Client for Pressure Ulcer Risk