A client recovering from a severe traumatic brain injury (TBI) is experiencing acute post-traumatic agitation. The client is highly restless, attempting to remove their cervical collar, and repeatedly trying to climb over the bed rails. Which intervention should the nurse prioritize to safeguard this client from harm?
- AApply a vest restraint to prevent the client from climbing out of bed and risking a secondary head injury.
- BDelegate the continuous monitoring and assessment of the client's neurological status to the unlicensed assistive personnel (UAP).
- Place the client in a low bed with surrounding safety mats and arrange for continuous direct supervision.Answer
- DLeave the room momentarily to administer a scheduled oral medication to a stable client down the hall.
Answer
The correct approach is to place the client in a low bed with surrounding safety mats and arrange for continuous direct supervision.
Using a low bed with floor mats and providing continuous direct supervision is a safe, effective, and least restrictive approach. It protects a restless client with a traumatic brain injury from falls and further trauma while prioritizing safety without the immediate use of physical restraints.
Step-by-Step Solution
Key Concept
Accident, Error, and Injury Prevention