A Nurse Identifies a Nursing Diagnosis of Risk for Falls

Multiple Choice

A nurse identifies a nursing diagnosis of Risk for falls when assessing a patient upon admission.The nurse and the patient agree that the goal is for the patient to remain free from falls.However,the patient fell just before shift change.What is the nurse's priority action when evaluating the patient's plan of care?

A) Counsel the nursing assistive personnel on duty when the patient fell.
B) Identify factors interfering with goal achievement.
C) Remove the fall risk sign from the patient's door because the patient has suffered a fall.
D) Request that the more experienced charge nurse complete the documentation about the fall.