Difficulty: Medium
Average Score: 84%
Simulated
A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?
Correct answer
A
Rationale
Hourly documentation ensures safety and legal compliance, though B (every 2 hours) is also correct per guidelines; A is prioritized for monitoring frequency. C neglects care, and D delays reassessment beyond typical 4-hour reviews.