A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication?

Choice A reason : Reducing stimuli is crucial for a patient emerging from a coma, especially after a traumatic brain injury (TBI). Excessive sensory input can overwhelm the patient's already compromised neurological state. The goal is to provide a calm and controlled environment to prevent overstimulation, which can lead to increased intracranial pressure (ICP), agitation, and delayed recovery. Interventions may include minimizing noise, dimming lights, and limiting the number of visitors. It's important to tailor the level of stimuli to the individual patient's response and recovery stage.

Choice B reason : Darkening the room can be part of reducing stimuli, but it is not the sole intervention needed. While a darker environment may help some patients rest, it is not universally applicable and should be considered as one aspect of an overall strategy to reduce stimuli. The nurse must assess the patient's individual needs and responses to determine if darkening the room is beneficial.

Choice C reason : The application of restraints is generally considered a last resort due to the potential for physical and psychological harm. Restraints can increase agitation and disorientation, potentially leading to self-injury or interference with medical devices. The use of restraints requires careful consideration, adherence to protocols, and often legal documentation. Non-pharmacological interventions and environmental modifications should be attempted first to manage restlessness.

Choice D reason : The administration of opioids is not typically indicated solely for restlessness in patients emerging from a coma. Opioids can depress the central nervous system, potentially masking neurological assessments and delaying recovery. They are primarily used for pain management. If restlessness is due to pain, then appropriate analgesia, including opioids, may be considered, but the underlying cause of restlessness should be thoroughly assessed and treated.

Choice A reason : Spironolactone is a potassium-sparing diuretic, which means it helps the body get rid of excess water without causing potassium loss. Therefore, a decreased potassium level would not be expected.

Choice B reason : Spironolactone can lead to hyperkalemia (increased potassium levels) and hyponatremia (decreased sodium levels) because it causes the kidneys to excrete sodium while retaining potassium.

Choice C reason : A decreased phosphate level is not a typical finding associated with spironolactone use. Phosphate levels are more commonly affected by renal function and parathyroid hormone levels.

Choice D reason : A decreased chloride level is not specifically associated with spironolactone. While electrolyte imbalances can occur, spironolactone primarily affects potassium and sodium balance.