A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Choice A reason: Providing more environmental stimulation may increase agitation in a client attempting to remove an IV, as heightened sensory input can exacerbate confusion or anxiety, potentially driven by altered brain signaling in delirium or dementia. This does not address the immediate need to secure the IV and prevent harm. Choice B reason: Covering the IV catheter to obscure it from view is a least-restrictive intervention, reducing the client’s focus on the device without physical or pharmacological restraint. This approach minimizes agitation, likely caused by cognitive or sensory processing issues, ensuring IV therapy continues safely while maintaining patient autonomy. Choice C reason: Waiting until tonight delays intervention, risking IV dislodgement and treatment disruption. The client’s behavior suggests underlying neurological or psychological factors, such as confusion, requiring immediate non-restrictive measures to secure the IV rather than observation, which could compromise care and patient safety. Choice D reason: Requesting a restraint prescription is restrictive and should be a last resort, as restraints can increase agitation or cause injury, potentially exacerbating stress-related cortisol release. Less invasive options, like covering the IV, should be tried first to address the behavior while preserving patient dignity and safety.