A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the clientÔÇÖs medical record? (Select all that apply)

E Names of staff members caring for the client C Attempts at less restrictive interventions A Observing range of motion of clientÔÇÖs extremities D Observation of the client once per hour B Providing opportunities for nutrition and toileting