A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?

A. Document in the client's medical record every 15 min: Frequent documentation is required to monitor the client’s safety, physical and psychological status, and ongoing need for restraints. This includes checking circulation, skin integrity, respiratory status, and mental condition. Documentation every 15 minutes ensures compliance with regulatory standards and provides a detailed record of care while the client is restrained. B. Offer toileting to the client every 4 hr: Clients in restraints should be offered toileting, hydration, and nutrition more frequently than every 4 hours, generally every 1–2 hours, to prevent complications such as skin breakdown, urinary retention, or dehydration. Waiting 4 hours is unsafe and does not meet standard restraint care guidelines. C. Remove the restraint when the client falls asleep: Restraints should not be removed solely based on sleep. Continuous monitoring is essential, and restraints are only removed or adjusted based on the client’s behavior, safety status, and provider orders. Sleep does not automatically indicate that the client is safe to be unrestrained. D. Request that the provider write an as-needed prescription for restraints: Restraints cannot be prescribed on an as-needed basis. They must be ordered with specific parameters including type, duration, and reason for use. Using restraints without a proper order or relying on as-needed instructions is outside legal and professional practice standards.