A nurse is caring for a client who is disoriented and is continuously getting out of bed. Which of the following actions should the nurse take? (Select all that apply.)

A. Only use restraints if the client becomes violent: Restraints should be used as a last resort when the client poses a danger to themselves or others. They are not meant for convenience or managing disorientation alone. B. Use seclusion to manage the client's behavior: Seclusion is typically reserved for managing severe aggression or self-harm in psychiatric settings. It is not an appropriate first-line intervention for a disoriented client attempting to get out of bed. C. Attempt the use of less restrictive methods before using restraints: The nurse should first implement interventions such as frequent monitoring, bed alarms, or sitter assistance. This approach prioritizes client safety while respecting autonomy and minimizing harm. D. Use restraints for the minimum amount of time necessary: If restraints are applied, they must be removed as soon as it is safe to do so to prevent physical and psychological complications, adhering to best practice and regulatory guidelines. E. Ensure the restraint limits the client's movement as little as possible: Proper application of restraints focuses on safety while allowing maximum mobility and comfort. Overly restrictive restraints can cause injury, skin breakdown, and additional stress.