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 actions should the nurse take to minimize the patient's risk for injury?

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