A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied permission to walk to the bathroom. While waiting to hear from the health care provider (HCP), which action should the nurse take?
a. Help the patient to get up on a bedside commode
b. Wait for the neurosurgeon to call back with orders
c. Page security to restrain the patient from harming the nurse
d. Administer an as-needed dose of a sedative that is ordered
ANS: D
Patients with subarachnoid hemorrhage are at risk for rebleeding. A. Straining to have a bowel movement and agitation both increase the risk of rebleeding. B. The patient may need to be sedated until the physician can be contacted. C. Bringing in security will be upsetting to the patient and can also increase the risk of raising the BP and bleeding.
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