A nurse is teaching a newly licensed nurse about the use of physical restraints. Which of the following directions should the nurse include in the teaching?

Restraints are restrictive interventions utilized only when less restrictive measures fail to ensure safety. Improper application can lead to asphyxiation or trauma, necessitating strict adherence to legal and ethical protocols regarding client rights and physical well-being. A. Completing an incident report is not a standard requirement for the simple initiation of a prescribed restraint. Incident reports are reserved for situations where an injury occurs or if a restraint was applied in an emergency without a prior order, rather than for routine educational directions on their general use. B. This choice is technically incorrect as provided in typical nursing curricula which state that for adults 18 years and older, the medical provider must renew the behavioral restraint prescription every 4 hr. An 8 hr interval is inappropriate and exceeds the maximum legal duration for a single behavioral prescription. C. Clinical protocols dictate that the least restrictive intervention must be attempted first. Chemical restraints, such as benzodiazepines or antipsychotics, are often considered less physically invasive or restrictive than mechanical ties, which can cause skin breakdown, nerve damage, or significant psychological distress and physical injury to the client. D. A seizure disorder is a significant contraindication because physical restraints can severely restrict the involuntary movements associated with tonic-clonic activity. Restricting these movements increases the risk of musculoskeletal trauma, fractures, and aspiration. Nursing care for seizures focuses on padding side rails and clearing the area rather than immobilization.