A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

A. Respect the client's need for social isolation:
While it's important to respect the client's need for moments of solitude and privacy, complete social isolation can lead to feelings of loneliness and exacerbate depressive symptoms. Balance is key; the nurse should encourage social interactions and support while respecting the client's need for personal space and alone time.

B. Encourage the client's family members to perform the client's ADLs:
Encouraging the client's family members to take over all activities of daily living (ADLs) can strip the client of their independence and self-efficacy. Instead, the nurse should support the client in actively participating in their self-care activities to the extent they are able. This promotes a sense of control and empowerment during a challenging time.

C. Discourage the client from talking about activities he did prior to the amputation:
Discouraging the client from discussing their life before the amputation can hinder the process of accepting the loss. Allowing the client to talk about their past experiences, activities, and memories can be therapeutic. It helps them process the grief associated with the amputation and allows for a healthy expression of emotions.

D. Determine the client's stage of grief:
Understanding the client's stage of grief is crucial. Grieving is a natural and individual process, and different people progress through stages like denial, anger, bargaining, depression, and acceptance at their own pace. By identifying the client's current stage of grief, the nurse can offer tailored support and interventions, ensuring the client's emotional needs are met effectively.

A. Request a prescription for varenicline from the client's provider.
Varenicline is used to help people quit smoking and is not indicated for the treatment of opioid use disorder.

B. Initiate facility procedures for emergency commitment.
Emergency commitment typically involves legal procedures and should only be pursued if the client poses an immediate danger to themselves or others. It is not the appropriate action in this scenario without further information indicating such a need.

C. Inform the client about policies for dispensing methadone.
Methadone is a medication used to help people reduce or quit their use of heroin or other opiates. Methadone is dispensed under strict regulations and guidelines due to its potential for misuse. The nurse should inform the client about the policies and procedures related to the dispensing of methadone, ensuring the client understands the rules and requirements associated with its use.

D. Assess the client using the CAGE questionnaire.
The CAGE questionnaire is a tool used to screen for alcohol use disorder, not opioid use disorder. While it's essential to assess the client comprehensively, using appropriate tools, in this case, informing the client about methadone dispensing policies is the most relevant action.