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?

Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.

Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.

Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.

Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.

Choice a) is incorrect because morphine sulfate is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that can relieve pain, anxiety, and dyspnea. Morphine sulfate can also reduce the preload and afterload of the heart, which can improve the cardiac output and oxygenation.

Choice b) is incorrect because laboratory testing of serum potassium is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that is important for the normal function of the cardiac cells and muscles. Serum potassium can be altered by various factors, such as renal function, acid-base balance, medications, or dietary intake. Serum potassium can affect the cardiac rhythm and contractility, which can influence the outcome of the client.

Choice c) is correct because 0.9% normal saline IV at 50 mL/hr continuous is a prescription that requires clarification for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that can maintain the fluid balance and blood pressure in the body. However, 0.9% normal saline can also cause fluid overload and worsen the heart failure symptoms, such as edema, crackles, and dyspnea. The nurse should clarify with the provider if this prescription is appropriate for the client's condition and if there are any parameters or limits for the fluid administration.

Choice d) is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that can increase the urine output and reduce the fluid volume and pressure in the body. Bumetanide can also decrease the preload and afterload of the heart, which can improve the cardiac output and oxygenation.