A client who has four-point restraints requires ongoing care after a violent episode. Which action should the nurse take?

• A. Provide range-of-motion exercises to all extremities every 2 hr.
• B. Request the provider renew the prescription in 24 hr.
• C. Keep staff interactions with the client to a minimum.
• D. Document the client's behavior in the medical record every 1 hr

Answer: (B)

The action being tested is ensuring ongoing, legally compliant safety for a client in four-point restraints. Restraints require a valid order that must be renewed regularly to continue their use; renewing the prescription within 24 hours ensures that there is current medical justification, allows ongoing reassessment of risk, and protects the patient from unnecessary restriction.

ROM exercises are not performed while restraints are in place, as movement could compromise safety or cause injury. Minimal staff interaction undermines safety and de-escalation, since restrained patients need consistent monitoring and support. Documentation is important, but the immediate priority is securing a renewed order to continue care within policy and safety standards.