Question

The staff nurse is caring for a client with a head injury who is restless and is pulling at the intravenous line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. Which is the most appropriate action by the nurse?

A. Ask a family member to sit with the client.
B. Ask a nursing assistant to monitor the client.
C. Stay with the client and consult with the nurse manager about the situation.
D. Tell the family that the application of wrist restraints is critical to prevent injury to the client.

Answer 1

The nurse should ask a family member to sit with the client, as this respects the family's request and the health care provider's decision against sedation and restraints, while ensuring patient safety.

Step-by-step explanation:

The most appropriate action by the nurse, when caring for a client with a head injury who is restless and pulling at the intravenous line, is to ask a family member to sit with the client. This approach respects the family's request for no restraints and the health care provider's decision to avoid sedation. Family involvement often has a calming effect on the patient, and the familial presence can aid in monitoring and ensuring the safety of the IV line and the patient overall. If a family member is unavailable or unable to fulfill this role, the nurse should then confer with the nurse manager or look into other patient-focused care options that align with the wishes of the client and family.