An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor, demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?

B Determine if the client is manifesting other neurologic changes. C Apply a restraining device to prevent the client from self injury. A Discuss with the family about placing the client in a skilled care facility. D Request family members report when the client is left alone.