The Nurse Is Caring for an Older Patient Who Has

Multiple Choice

The nurse is caring for an older patient who has a non-weight-bearing cast on the left lower extremity.The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance.Which response by the nurse is most likely to keep the patient from falling?

A) Apply a vest restraint and offer frequent toileting.
B) Plan fall prevention with patient, family, and health care provider.
C) Inform family that the patient needs physical restraints.
D) Document that the patient has a high potential for falling.