A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior.Which of the following actions should the nurse take?

Choice A rationaleDocumenting the client's behavior every 1 hour is not sufficient in this case. Restraints require continuous monitoring and more frequent documentation to ensure the client's safety.Choice B rationaleMinimizing staff interactions could increase the client's agitation and sense of isolation, which is counterproductive to their well-being.Choice C rationaleRestraint orders need to be reviewed and renewed more frequently than every 24 hours to ensure continued necessity and appropriateness. Typically, restraint orders should be reviewed every 4 hours for adults.Choice D rationaleProviding range-of-motion exercises every 2 hours helps to prevent complications associated with immobility, such as muscle atrophy, contractures, and pressure ulcers.