A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A. Place her in a jacket restraint.
B. Wrap her hands in soft “mitten” restraints.
C. Tuck her arms and hands under the draw sheet.
D. Apply a wrist restraint to each arm.
Correct Answer: B. Wrap her hands in soft “mitten” restraints.
It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Communicate therapeutically with the patient and answer questions calmly and honestly. Promotes a calm and supportive environment.
Option A: Using a jacket would increase her agitation and increase ICP. Clarify any misinformation and answer all questions honestly and in simple understandable language. Prevents unnecessary anxiety resulting from inaccurate information or beliefs.
Option C: Tucking the client’s arms and hands under the draw sheet restricts movement and adds to feelings of being confined. Explain the reason for and what to expect for each procedure or type of therapy; use drawings and pictures, videotapes for the client. Reduces fear which causes anxiety.
Option D: Applying wrist restraints restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP. Allow expressions of concern and opportunity to ask questions about condition and recovery of the client. Provides an opportunity to vent feelings, secure information needed to reduce anxiety.
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