Final Exam Modules 8 - 10: NUR2356 / NUR 2356 (Latest 2024 / 2025) Multidimensional Care I / MDC 1 | Questions and Verified Answers | 100% Correct | Grade A - Rasmussen
Question:
The STAND bundle was developed to describe the interventions to:
Answer:
• Score (using the Braden Scale fo...
Final Exam Modules 8 - 10:
NUR2356 / NUR 2356 (Latest 2024 /
2025) Multidimensional Care I /
MDC 1 | Questions and Verified
Answers | 100% Correct | Grade A -
Rasmussen
Question:
The STAND bundle was developed to describe the interventions to:
Answer:
• Score (using the Braden Scale for Predicting Pressure Injury Risk)
• Turn (repositioning tubes and devices, turning the patient)
• Apply (bordered foam dressing or barrier cream)
• Nutrition (attention given to nutrition status)
• Discuss (involvement of specialists)
,Question:
what is included in the Braden Scale?
Answer:
commonly used valid skin risk assessment tool. Using it helps the nurse
assess and document risk categories for pressure injury formation (e.g.,
mental status, activity and mobility, nutritional status, incontinence).
Question:
Focused assessment: The patient at risk for pressure injuries
ASSESS CARDIOVASCULAR STATUS
Answer:
• Presence or absence of peripheral edema
• Hand-vein filling in the dependent position
• Neck-vein filling in the recumbent and sitting positions
• Weight gain or loss
Question:
Focused assessment: The patient at risk for pressure injuries
ASSESS COGNITION AND MENTAL STATUS
Answer:
• Level of consciousness
, • Orientation to time, place, and person
Question:
Focused assessment: The patient at risk for pressure injuries
ASSESS NUTRITION STATUS
Answer:
• Change in muscle mass
• Lackluster nails, sparse hair
• Recent weight loss of more than 5% of usual weight
• Impaired oral intake
• Difficulty swallowing
• Generalized edema
• Intact skin with localized area of nonblanchable erythema (may appear
differently in skin with darker pigmentation).
• May be preceded by changes in sensation, temperature, or firmness.
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