A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?

Choice A reason: Keeping restraints on for a set minimum like 1 hour ignores the least restrictive principle, risking harm if the child calms sooner. Restraints require frequent reassessment, not arbitrary duration, to ensure safety and circulation. This rigid approach violates guidelines, making it unsafe and inappropriate. Choice B reason: Monitoring vital signs every 15 minutes ensures the child’s safety in restraints, detecting distress, hypoxia, or injury from aggression or positioning. Conduct disorder doesn’t negate physiological risks, and standards mandate close observation. This action prioritizes well-being, aligning with protocol, making it the correct choice. Choice C reason: Renewing restraint orders every 24 hours is standard but not immediate; it addresses future use, not current safety post-initiation. The priority is real-time monitoring, not administrative renewal. This action delays focus on the child’s acute state, so it’s not the top priority now. Choice D reason: An in-person evaluation within 2 hours is ideal but secondary to immediate safety checks like vital signs. Regulations often allow 1-4 hours for provider review, depending on age, but monitoring precedes this. It’s important but not the first action, making it less urgent.