A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Choice A reason : Reducing stimuli is crucial for a patient emerging from a coma, especially after a traumatic brain injury (TBI). Excessive sensory input can overwhelm the patient's already compromised neurological state. The goal is to provide a calm and controlled environment to prevent overstimulation, which can lead to increased intracranial pressure (ICP), agitation, and delayed recovery. Interventions may include minimizing noise, dimming lights, and limiting the number of visitors. It's important to tailor the level of stimuli to the individual patient's response and recovery stage.

Choice B reason : Darkening the room can be part of reducing stimuli, but it is not the sole intervention needed. While a darker environment may help some patients rest, it is not universally applicable and should be considered as one aspect of an overall strategy to reduce stimuli. The nurse must assess the patient's individual needs and responses to determine if darkening the room is beneficial.

Choice C reason : The application of restraints is generally considered a last resort due to the potential for physical and psychological harm. Restraints can increase agitation and disorientation, potentially leading to self-injury or interference with medical devices. The use of restraints requires careful consideration, adherence to protocols, and often legal documentation. Non-pharmacological interventions and environmental modifications should be attempted first to manage restlessness.

Choice D reason : The administration of opioids is not typically indicated solely for restlessness in patients emerging from a coma. Opioids can depress the central nervous system, potentially masking neurological assessments and delaying recovery. They are primarily used for pain management. If restlessness is due to pain, then appropriate analgesia, including opioids, may be considered, but the underlying cause of restlessness should be thoroughly assessed and treated.

Choice A reason : Nitroglycerin is used to treat angina pectoris and does not typically cause a decrease in potassium levels¹.

Choice B reason : Metoprolol is a beta-blocker used to treat high blood pressure and heart failure but is not known to significantly affect potassium levels¹.

Choice C reason : Spironolactone is a potassium-sparing diuretic and would not contribute to low potassium levels; it is more likely to cause hyperkalemia¹.

Choice D reason : Furosemide is a loop diuretic that can lead to hypokalemia by increasing the excretion of potassium in the urine. It is known to contribute to low potassium levels and should be identified as the medication affecting this lab value¹².