A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?

A. Document the client's behavior hourly on a flow sheet: While documentation is important, it is more frequent than hourly. Clients in restraints should be observed and documented on more frequently, usually every 15 minutes to ensure safety and assess the client's condition.

B. Request a PRN client prescription for restraints from the provider: Restraints require a specific order from the provider, not a PRN (as needed) prescription. The order must be obtained initially and renewed per the facility's policy, typically every 24 hours.

C. Observe the client's behavior once every 15 minutes: Clients in restraints must be closely monitored for safety and well-being. The nurse should assess the client’s condition, including physical and emotional status, every 15 minutes.

D. Remove the restraint when the client calmly follows commands: Restraints should only be removed under appropriate conditions as assessed by the nurse, and with a provider’s order when necessary. The client's behavior alone does not determine the removal of restraints.

A. "The honeymoon stage of violence usually gets longer over time": The honeymoon stage typically becomes shorter as the cycle of abuse progresses. Over time, the tension-building and abusive episodes tend to increase in frequency and intensity.
B. "Survivors of abuse often feel guilty": Survivors of intimate partner abuse often feel guilty, ashamed, or responsible for the abuse. They may believe they somehow provoked the violence or could have prevented it.
C. "As abuse continues, victims become more determined to be independent": Victims of abuse often become more dependent over time due to manipulation, fear, and control exerted by the abuser. They may find it difficult to leave or make independent decisions.
D. "Abusers often have high self-esteem": This statement is generally inaccurate as abusers often have low self-esteem and may use controlling behaviors as a way to mask feelings of inadequacy or insecurity.