The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take? (Select all that apply.)

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The nurse instructs the patient to walk 10 feet (3 m) as quickly and safely as possible and observes for unsteadiness in the patient's gait. For accuracy, a patient should have one practice trial that is not included in the score. Patient taking less than 20 seconds to complete TUG is adequate for independent mobility. Score over 30 seconds is dependent and at risk for fall. Counting does not begin after instructions. The patient rises from a straight back chair without using arms for support.

The Nurse Is Performing the "Timed Get Up and Go