When the Patient Turns His Head Quickly During the Admission

Multiple Choice

When the patient turns his head quickly during the admission assessment,the nurse observes nystagmus. What is the indicated nursing action?

A) Assess the patient with a Rinne test.
B) Place a fall-risk bracelet on the patient.
C) Ask the patient to watch the mouths of staff when they are speaking.
D) Remind unlicensed assistive personnel to speak loudly to the patient.