A nurse is caring for a client who has become aggressive and requires the placement of wrist restraints to maintain the client's safety. Which of the following actions should the nurse take?

Introduction: Physical restraints are emergency safety interventions used only when less restrictive measures fail. Their use requires rigorous neurovascular monitoring to prevent complications such as peripheral nerve damage, pressure injuries, or localized ischemia, ensuring the intervention does not cause further physiological harm to the client. A. The nurse must frequently assess the neurovascular status of the restrained limbs, checking for pulse, color, temperature, and capillary refill. Physical restraints pose a high risk for circulatory impairment and nerve compression. Frequent observation ensures early detection of ischemia, which could lead to permanent tissue damage if left unaddressed. B. Tying a restraint to the bed rail is a dangerous practice and a violation of safety standards. Bed rails are mobile; if the rail is lowered or moved, it can cause sudden tension on the restraint, leading to limb fractures or dislocations. Restraints must always be secured to the stationary bed frame. C. In an acute aggressive situation requiring restraints, vital signs and the client's status must be monitored much more frequently than every 4 hours. Most protocols require continuous observation or assessments every 15 minutes to ensure the client's respiratory and cardiovascular stability, as agitation increases the metabolic demand on the body. D. Using square knots is prohibited because they cannot be released quickly in an emergency. All medical restraints must be secured with a quick-release knot (such as a half-bow) to ensure that staff can immediately free the client in the event of a fire, vomiting, or cardiac arrest.