59. A patient is confused and attempts to climb out of bed, posing a fall risk. After exhausting less restrictive measures, the team decides to apply soft wrist restraints. What is a critical nursing responsibility immediately after applying restraints?

  • Leave the patient unattended to rest
  • Document the reason for restraint and ongoing assessment, and release criteria
  • Reassure the patient that they are being punished
  • Apply restraints loosely to prevent injury
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