A nurse is providing care for a client who has a central venous access device. Which of the following actions should the nurse take when providing site care?

Rationale

• Encourage rigorous physical exercise to enhance mobility: While exercise can improve function, rigorous or high-intensity activity may exacerbate fatigue or trigger worsening of symptoms in MS. Exercise should be tailored to the client’s tolerance and done under professional guidance rather than encouraged rigorously at home. Overexertion may increase relapse risk or cause injury.

• Instruct the client to remove throw rugs from their home: Removing throw rugs reduces the risk of falls in clients with multiple sclerosis, especially those who have had gait disturbances or lower extremity weakness. Fall prevention is a standard safety intervention in MS care. This addresses environmental hazards and promotes safe ambulation at home.

• Request a provider referral for physical therapy: Physical therapy supports mobility, balance, and strength in clients with MS. PT interventions can help manage spasticity and prevent functional decline. Referral is appropriate for clients who continue to experience daily muscle spasms and intermittent functional limitations.

• Teach the client about self-administering glatiramer acetate: Glatiramer acetate is a disease-modifying therapy for MS, and teaching self-administration promotes adherence, autonomy, and consistent treatment. Education regarding proper technique, injection site rotation, and monitoring for side effects is a standard nursing intervention in MS management.

• Encourage the use of a hot tub to decrease muscle spasms: Hot tubs can exacerbate heat sensitivity in MS, potentially worsening muscle weakness, fatigue, or neurological symptoms. Heat intolerance is common in MS, making hot tub use an inappropriate intervention without professional guidance. Safer spasticity management strategies include stretching, PT, or pharmacologic interventions.

A. Bone is exposed within the wound: Exposure of bone indicates a stage IV pressure injury, which involves full-thickness tissue loss with exposed muscle, tendon, or bone. This is more severe than stage III.

B. The skin is reddened and intact: Reddened, intact skin corresponds to a stage I pressure injury, which involves non-blanchable erythema without skin breakdown.

C. Subcutaneous fat is visible: Stage III pressure injuries involve full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. This finding is consistent with stage III classification.

D. Slough and eschar is present: While slough and eschar may be present in stage III or IV injuries, the presence alone is not sufficient to determine stage. The key characteristic for stage III is full-thickness tissue loss with visible subcutaneous fat without exposed deeper structures.