The Nurse Observes Signs That a Patient May Be Experiencing

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII) . Which action by the nurse is most appropriate for minimizing the patient's risk for injury?. Select all that apply.

A) Identify the patient's fall risk category.
B) Assess the patient's gag reflex prior to offering food or liquids.
C) Assist the patient with bedside sitting or toileting.
D) Assess the patient's vision using a Snellen chart.
E) Place a red "falls risk" bracelet on the patient's arm.