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
Choice A reason: Verbalizing anger does not indicate that the client is safe to have restraints removed. Anger can escalate into physical aggression, and removal of restraints under these conditions could endanger staff and the client. Choice B reason: The provider does not need to be physically present to remove restraints. Nurses are responsible for ongoing assessment and can remove restraints when criteria are met, following facility protocols. Waiting for the provider could delay appropriate care and prolong unnecessary restraint use. Choice C reason: The client must be calm and cooperative before restraints can be safely removed. This ensures that the risk of harm to self or others has decreased and that the client can be managed without physical restriction. Calm and cooperative behavior demonstrates readiness for restraint discontinuation. Choice D reason: Verbalizing remorse is not a requirement for removing restraints. Remorse is a subjective emotional response and does not guarantee safety. The focus must be on observable behavior—calmness and cooperation—rather than emotional expressions.