A nurse in the ICU is caring for a patient who has just been admitted after sustaining a closed head injury in a motor vehicle accident. The patient is awake, disoriented, and combative. The patient has an order for 4-point restraints to prevent the patient from pulling at IV lines and causing injury to self or others. The nurse knows that the patient's plan of care will include which of the following interventions?

Neurological assessment at least every 30 to 60 minutes while in the intensive care unit.

Explanation

• Patients with closed head injury will be placed on frequent neurological checks and assessments, usually every 30 to 60 minutes, while in the ICU.

Incorrect options:

• A patient with a closed head injury after an accident may be confused and combative. These patients may be restrained to prevent injuring themselves or others. With a restrained patient, the nurse will remove or loosen the restraints one at a time for a few minutes every 2 hours or according to hospital policy, and then replace the restraints until it is determined that they are not needed for patient safety.

• Haloperidol or other antipsychotics may or may not be ordered based on the doctor's assessment of the patient's condition.

• Maintaining a low level of light and decreased external stimuli can actually increase the patient's combativeness or disorientation.

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