A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

A. Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs. B. It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary. C. Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use. D. The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.