RN Nursing · Pressure Injury, Wounds, and Wound Management · Practice question
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
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"The client's age is part of the measurement."
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"The higher the score, the higher the pressure injury risk."
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✓
"The scale measures six elements."
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"Each element has a range from one to five points."
Answer & explanation
Correct: "The scale measures six elements."
The Braden Scale is a widely used tool for predicting pressure injury risk. It assesses six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each subscale is scored on a range of 1 to 4, except for friction and shear, which is scored 1 to 3. The total score ranges from 6 to 23. A lower Braden score indicates higher risk for pressure injury, while a higher score indicates lower risk — the opposite of what the distractor states. The client's age is not one of the six measured elements, making that statement incorrect. Each element does not have a range of one to five; most range from one to four, and friction and shear only goes up to three. The statement that the scale measures six elements is accurate and correctly demonstrates understanding of the teaching. Students often confuse the direction of scoring (assuming higher scores mean higher risk) or the number of elements, so remembering that lower scores equal higher risk and that there are exactly six subscales is essential for both clinical practice and exam success.
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