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    ATI Nur 223 Mental Health proctored Exam

    A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

    Explanation & Rationale

    Choice A reason: Darkening the room may help but is less comprehensive than reducing all stimuli. Noise, light, and activity can exacerbate restlessness, so a broader approach is needed, making this incorrect. Choice B reason: Applying restraints can increase agitation and injury risk in a restless client. Non-restrictive calming measures are preferred, making this incorrect for managing post-coma restlessness safely. Choice C reason: Opioids may sedate but risk respiratory depression and mask neurological changes. Reducing stimuli is safer and addresses restlessness directly, making this incorrect for the care plan. Choice D reason: Reducing stimuli, like noise and activity, calms the client emerging from a coma, preventing agitation. This aligns with TBI care to promote recovery, making it the correct intervention.

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