A client with herpes zoster is inquiring about the use of complementary and alternative therapies for pain management.
Which therapy should the nurse inform the client is contraindicated for their condition?

Choice A rationale

Using an extension cord to watch television in the living room does not indicate effective learning about using a walker. Extension cords can create a tripping hazard, which is particularly dangerous for someone using a walker.

Choice B rationale

Hiring someone to trim the tree that overhangs the front porch stairs indicates an understanding of the need to remove potential obstacles that could interfere with the safe use of the walker.

Choice C rationale

Placing the alarm clock on the bedroom dresser does not demonstrate an understanding of how to use a walker safely. It does not address any of the key safety considerations associated with walker use.

Choice D rationale

Replacing the old throw rug in the kitchen with a new one does not necessarily indicate effective learning about using a walker. Throw rugs can be a tripping hazard for individuals using a walker, regardless of whether they are old or new.

Choice A rationale

The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.

Choice B rationale

The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.

The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative

pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.

Choice C rationale

The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.

Choice D rationale

The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.