A nurse is educating a patient with multiple sclerosis who has been prescribed baclofen. What guidance should the nurse include in the education?

Choice A rationale

Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying

tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.

Choice B rationale

Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.

Choice C rationale

Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.

Choice D rationale

Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.

Choice A rationale

While it is within the nurse’s scope of practice to communicate with the doctor regarding the patient’s condition, applying restraints should not be the first course of action when a patient frequently tries to remove their IV catheter. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice B rationale

This is the correct response. Covering the catheter so the patient can’t see it may help to reduce the patient’s urge to remove it. This is a non-invasive intervention that respects the patient’s autonomy while also ensuring their safety.

Choice C rationale

Waiting until nighttime to see if the patient continues the behavior may not be the best course of action. If the patient is frequently trying to remove their IV catheter, it is important to address the issue promptly to prevent potential harm.

Choice D rationale

Applying restraints immediately is not the best course of action. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.