The Nurse Is Caring for a Patient in Restraints

The nurse is caring for a patient in restraints.Which of the following pieces of information about restraints requires nursing documentation in the medical record?

A) The patient states that her gown is soiled and needs changing.
B) Attempts to distract the patient with television are unsuccessful.
C) The patient has been placed in bilateral wrist restraints at 0815.
D) One family member has gone to lunch.
E) Bilateral radial pulses present, 2+, hands warm to touch
F) Released from restraints, active range-of-motion exercises complete