A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take?

Choice A reason : Conducting 15-minute checks can be part of the safety measures for a client at risk of self-harm, but it may not be sufficient for someone who is actively hearing voices commanding self-harm and refusing to engage in safety planning. These checks are less intensive and may not provide the immediate intervention needed to ensure the client's safety¹.

Choice B reason : Encouraging the client to express feelings related to suicide is an important therapeutic intervention that can provide insight into the client's emotional state and risk factors. However, if the client is actively psychotic and not engaging in safety planning, this approach alone may not be enough to ensure immediate safety¹.

Choice C reason : Placing the client on one-to-one observation is the most direct and immediate intervention to ensure safety when a client is experiencing psychotic features and is at risk of self-harm. This level of observation means that the client is never alone, and a staff member is always present to intervene if the client attempts self-harm¹.

Choice D reason : Obtaining an order for locked seclusion can be considered if other less restrictive measures are not sufficient to ensure the client's safety. However, it is generally a last resort due to the potential for negative psychological effects and should only be used when absolutely necessary and when other interventions have failed¹.

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.