A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

Choice A rationale Family notification is a secondary administrative task rather than a priority clinical assessment. While families have a right to be informed about falls, asking them to provide sitters places an inappropriate burden on the family and shifts the facility's responsibility for safety onto them. The nurse must first ensure the client is physically stable and uninjured before proceeding with any notification or long-term safety planning. Choice B rationale Moving a client back into bed before assessing for potential fractures or head trauma can cause significant harm or exacerbate internal injuries. Furthermore, the application of restraints is strictly regulated and generally considered a last resort. Restraints can increase the risk of agitation and further injury. The legal and ethical standards for restraint use require a specific medical necessity that is not met by a fall alone. Choice C rationale Immediate physical assessment is the priority action when a client is found on the floor to identify life-threatening injuries or fractures. The nurse must check for head trauma, limb deformity, and pain before moving the client. Assessment ensures that the client is moved safely and that necessary medical interventions are initiated. This follows the nursing process by prioritizing data collection and safety over administrative or delegated tasks. Choice D rationale Chemical sedation is an inappropriate response to a fall and can significantly increase the risk of future falls due to altered mental status and impaired motor coordination. Sedatives are not a substitute for proper safety monitoring or environmental modifications. Prescribing medication without a clear medical diagnosis for its use violates standard practice and does not address the underlying cause of why the client was found on the floor.