A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Explanation & Rationale
A. The nurse should assess the client’s need for toileting regularly, as restricted movement can increase the risk of discomfort and physical harm. Monitoring this every 15 minutes is recommended for ensuring the client's basic needs are met. B. Physical restraint prescriptions should be renewed at intervals that are consistent with the facility’s policies, but every 8 hours is typically too long. A more frequent reassessment should occur. C. Clients in restraints should be monitored more frequently than every 30 minutes to ensure their safety and well-being, especially in terms of physical comfort and circulation. D. Offering hydration and nutrition every 2 hours may not be necessary if the client is receiving fluids and food regularly, but they should be monitored more frequently for other immediate needs.