The nurse is caring for an eight-year-old child who has been in a car accident, has a head injury, and is in the ICU. The nurse sees the child pulling on the IV line. What action should the nurse take?
1. Sedate the child as needed.
2. Place soft wrist restraints on the child.
3. Ask the parents to watch the child closely at all times.
4. Tell the child not to pull on the IV line.
2
Rationale 1: Due to the head injury, it is not feasible to sedate the child.
Rationale 2: Children may interfere with treatment by pulling or removing medical devices; soft restraints may be necessary to prevent them from pulling on or removing medical devices.
Rationale 3: It is not feasible for the parents to watch the child at all times.
Rationale 4: The child may not understand what the nurse is trying to convey.
Global Rationale:
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