A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

Rationale: A. While clients in restraints must be monitored frequently (typically at least every 15–30 minutes depending on policy), ongoing monitoring is not the priority when the client is calm and no longer exhibiting behavior that necessitates restraints. The nurse should first reassess the need for restraints. B. Restraints must be discontinued as soon as the client is no longer a danger to themselves or others. Since the client is now calm and cooperative, continued restraint use is no longer justified and may lead to complications such as impaired circulation, skin breakdown, and psychological distress. The nurse should remove restraints promptly while ensuring safety. C. While therapeutic activities may be appropriate after stabilization, the immediate priority is discontinuation of restraints. Participation in group therapy is not the priority action in this situation. D. There is no indication of pain in the question stem, and medication is not the priority intervention. The nurse must first discontinue restraints once the client’s behavior is under control and safety is restored.