As a nurse, Recognize Cues in this scenario with focus on safety. Sue is a 93-year-old Caucasian female admitted to a facility 3 days ago. She experienced a fall early this morning. Sue has slept only 3 hours per night. She is restless and anxious and often cries out for her husband. She frequently attempts to get out of bed by herself. She requires one assist to transfer from the bed to chair or to ambulate to the bathroom, but forgets to call for help when getting up. Also, she is not oriented to person, place, time, or situation. Past medical history is as follows: advanced Alzheimers disease x 7 years, Type 2 diabetes mellitus x 20 years, Hypertension x 5 years, Osteoarthritis, Depression, and history of falls at home. This morning, she was found on the floor beside her bed, she was incontinent of urine and was crying out for her husband. You note a 5cm x 4cm abrasion to her right hip, the provider was notified and an order for lorazepam 1mg PO now was received. Vital signs: Temp 97.6 F, HR 72bpm, RR 16 breaths/min, BP 142/90 mm Hg. SaO2 94% room air. Blood sugar 83 mg/dL. Skin: pink, warm, dry; 5cm x 4cm abrasion to right hip.