A nurse is caring for a postoperative client who received a dose of opioid pain medication 30 min ago. The client is now requesting another dose of pain medication to relieve continuing acute pain. Which of the following actions should the nurse take first?

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.