A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?
A) Restrain the patient as ordered.
B) Administer opioids PRN as ordered.
C) Arrange for friends and family members to sit with the patient.
D) Pad the side rails of the patient's bed.
Ans: D
Feedback:
To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless patients should be avoided because these medications can depress respiration, constrict the pupils, and alter the patient's responsiveness. Visitors should be limited if the patient is agitated.
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