A night shift nurse has a client who is confused and withdrawing from alcohol. He is currently in 4 point restraints after attempting to attack one of the nurses. What is the most appropriate action for the nurse to take during his shift?
Ensure the physician has renewed the order for restraints, as this should be done every 12 hours.
Have the attending physician discontinue the restraints to give the client a chance to behave more appropriately.
Assess the patient’s skin integrity around the restraints hourly.
Release the leg restraints to give the client a break and see if combative behavior has gotten better.
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