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 must be documented by the nurse in the medical record? (Select all that apply. )

A) The patient states that her gown is soiled and needs changing.
B) Previous attempts to distract the patient with television were unsuccessful.
C) The patient was 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.