A nurse in the emergency department is assessing a preschool-age child who has bruises on both arms and a spiral fracture of the left ulna. The child's parent tells the nurse that the child tripped over some toys and fell down. Which of the following actions should the nurse take?

Choice A reason: Obtaining a prescription for a sedative for the client is not a correct action, as it may cause adverse effects such as confusion, falls, or respiratory depression. The nurse should avoid using sedatives unless absolutely necessary and use non-pharmacological interventions to calm the client.

Choice B reason: Removing the clock and calendar from the client's room is not a correct action, as it may worsen the client's disorientation and anxiety. The nurse should provide orientation cues such as a clock, a calendar, a radio, or a newspaper to help the client maintain a sense of time and reality.

Choice C reason: Providing distractions for the client during the day is a correct action, as it may reduce the client's boredom, agitation, and wandering behavior. The nurse should engage the client in meaningful activities such as music, games, crafts, or exercise that suit the client's interests and abilities.

Choice D reason: Raising all four side rails on the client's bed is not a correct action, as it may increase the risk of injury or entrapment if the client tries to climb over them. The nurse should use the least restrictive measures to prevent wandering, such as alarms, locks, or supervision.

Choice A reason: Notifying staff of the increased fall rate is not the first action that the nurse should take, as it does not address the root cause of the problem or the possible solutions. The nurse should inform the staff of the fall rate after conducting a thorough analysis and developing a plan of action.

Choice B reason: Identifying clients who are at risk for falls is the first action that the nurse should take, as it helps to determine the scope and severity of the problem and the factors that contribute to it. The nurse should use a valid and reliable tool to assess the fall risk of each client and document the findings.

Choice C reason: Reviewing current literature regarding client falls is not the first action that the nurse should take, as it does not provide specific information about the facility's situation or the client's needs. The nurse should review the literature after identifying the clients who are at risk for falls and before implementing a fall prevention plan.

Choice D reason: Implementing a fall prevention plan is not the first action that the nurse should take, as it requires evidence-based interventions and evaluation methods that are tailored to the facility's context and the client's characteristics. The nurse should implement a fall prevention plan after reviewing the current literature and obtaining approval from the stakeholders.