The nursing staff are caring for a confused patient who is at risk for falling.
What action by the nurse would be appropriate in order to avoid restraining the patient?

Choice A rationale:

Assessing the strength of the lower extremities is one of the objectives of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action helps evaluate the muscle strength of the lower limbs, providing information about the patient's neuromuscular function.

Choice B rationale:

Assessing the patient's sense of balance is another objective of this action. Dorsiflexion and plantarflexion require coordination and balance. If the patient struggles to maintain balance while performing these movements, it could indicate issues with proprioception or neurological deficits.

Choice C rationale:

Assessing the presence of edema is not directly related to dorsiflexion and plantarflexion movements. Edema assessment typically involves inspecting and palpating specific areas of the body, such as the ankles, to check for swelling, discoloration, and pitting.

Choice D rationale:

Evaluating the range of motion of the ankle joint is a key aspect of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action allows the nurse to observe how far the patient can move their ankles, providing valuable information about joint flexibility and function.

Choice E rationale:

Assessing the status of the patient's skin turgor involves checking the skin's elasticity and hydration level, usually by pinching and observing how quickly the skin returns to its normal position. This assessment is unrelated to the dorsiflexion and plantarflexion movements and is not applicable in this context.