Certified Wound Care Nurse (CWCN) Practice Exam

A developmentally delayed patient who turns when reminded is assigned what score for Sensory Perception on the Braden Scale?

1. 1

2. 2

3. 3

4. 4

The correct answer is: 2

On the Braden Scale, the scores for Sensory Perception range from 1 to 4, indicating varying levels of ability to respond to pressure-related discomfort. A score of 2 suggests that the patient has a limited ability to sense pressure. Specifically, this score reflects the patient’s capacity to respond or react only with verbal or physical prompts. In this context, the developmentally delayed patient who requires reminders to turn indicates that while there is some ability to respond to discomfort, it is not consistent or automatic without prompting. This assessment is crucial in predicting the risk of pressure ulcers, as a lower score correlates with a higher risk. A score of 2 acknowledges the patient’s responsiveness to cues while highlighting the limitations in self-initiated actions, which is consistent with their developmentally delayed status. The other scores on the scale denote either a complete lack of sensory perception or a greater degree of independent responsiveness, which would not accurately represent this patient's condition.