A nurse is assisting with the care of a client.

Exhibits

A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Choice A reason : While nasopharyngeal suctioning may be necessary to clear secretions, it should be done with the client's consent and in a manner that maintains their dignity. It is not the primary action to support dignity.

Choice B reason : Giving the client privacy during care is a fundamental way to support their dignity. It respects their personal space and autonomy, even in a vulnerable state.

Choice C reason : Demonstrating empathy is crucial in end-of-life care, as it acknowledges the client's feelings and experiences. However, it is not an action but rather an approach or attitude.

Choice D reason : Providing care with an optimistic attitude can be supportive, but it must be balanced with realism, especially in end-of-life situations where the focus is on comfort and dignity.

Choice E reason : Telling the client that their condition will improve may not be appropriate in end-of-life care, as it may not be truthful and could undermine trust.

Choice A reason : Trust vs. Mistrust.The stage of Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development, occurring from birth to approximately 18 months of age. In this stage, the infant is uncertain about the world and looks towards their primary caregiver for stability and consistency of care. If the caregiver is reliable, consistent, and nurturing, the child will develop a sense of trust, believing that the world is safe and that people are dependable and affectionate. This sense of trust allows the child to feel secure even when threatened and extends into their other relationships, maintaining their sense of security amidst potential threats.

Choice B reason : Autonomy vs. Shame and Doubt.The stage of Autonomy vs. Shame and Doubt is the second stage of Erikson's theory, spanning the toddler years from 18 months to three years. In this stage, toddlers begin to assert their independence by making choices and taking control over their actions. Success in this stage leads to feelings of autonomy, while failure results in feelings of shame and doubt. However, this stage is not applicable to the scenario described, as it involves an infant, not a toddler.

Choice C reason : Identity vs. Role Confusion.Identity vs. Role Confusion is the fifth stage, occurring during the teen years from 12 to 18. This stage is characterized by the exploration of personal identity and the development of a sense of self. The scenario provided does not pertain to an adolescent, so this stage is not relevant to the infant's experience.

Choice D reason : Integrity vs. Despair.The stage of Integrity vs. Despair is the eighth and final stage of Erikson's theory, occurring in older adulthood from 65 to death. This stage involves reflecting on one's life and either concluding it with a sense of integrity and fulfillment or with a sense of despair over a life misspent. This stage is not applicable to the infant described in the scenario.