A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?
Explanation & Rationale
A. The client must be calm and cooperative. Restraints should be removed as soon as the client is calm and no longer poses a threat to themselves or others. Continued use without justification can be considered unethical and unlawful. B. The client must verbalize remorse for their behavior. Remorse is not a requirement for restraint removal. Some clients may lack insight into their actions due to mental illness or cognitive impairment. The focus should be on safety, not forced expressions of regret. C. The client only verbalizes anger toward the staff. Expressing anger alone is not a justification for continued restraint. As long as the client is not aggressive or violent, they should not remain restrained. D. The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. Nurses can remove restraints without the provider physically present if the client meets the criteria for release. However, they must document the assessment and notify the provider.