Difficulty: Medium
Average Score: 85%
Simulated
When placing an agitated client in restraints
Correct answer
A,C,D
Rationale
The correct answer is A, C, and D. A is correct because before placing an agitated client in restraints, the nurse must understand the necessity of using the least restrictive measures first. C is correct because in most cases, the physician should be present or informed before restraints are applied. D is correct as turning the client every 2 hours is essential to prevent complications like pressure ulcers. B is incorrect because documentation should include interventions attempted, but it's not the primary consideration before restraints. E is incorrect because monitoring every one-half hour may not be necessary unless the client's condition warrants more frequent checks.