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 : Going to bed at the same time every night, even when not feeling tired, can help regulate the body's clock and aid in falling asleep at a regular time. However, lying in bed awake can lead to frustration and should be avoided. If sleep does not come within 20 minutes, it's recommended to get up and do something relaxing until feeling sleepy.

Choice B reason : Exercising can increase alertness and endorphin levels which can make it difficult to fall asleep if done too close to bedtime. Stopping exercise at least 2 hours before bedtime allows the body to wind down and prepare for sleep, making this statement correct and indicative of an understanding of good sleep hygiene practices.

Choice C reason : Watching television or engaging in other stimulating activities in the bedroom can associate the space with wakefulness rather than sleep. The light from screens can also suppress melatonin production, making it harder to fall asleep. Therefore, this statement does not reflect an understanding of the teaching on good sleep practices.

Choice D reason : Taking long naps, especially in the late afternoon or evening, can interfere with nighttime sleep. If naps are necessary, they should be limited to 20-30 minutes and taken earlier in the day. This statement suggests a misunderstanding of the impact of napping on sleep quality at night.

Choice A reason : Prolonged grief, also known as complicated grief, is characterized by an intense longing and preoccupation with thoughts or memories of a loved one, which persists long after the loss has occurred. It can significantly impair important areas of functioning and is defined by the DSM-5-TR as grief that stays with you long-term. The client's inability to accept the loss after three years suggests that they may be experiencing prolonged grief, which may require the guidance of a mental health professional for resolution.

Choice B reason : Uncomplicated grief, also known as normal grief, involves a range of feelings, including sadness, anger, and longing, that gradually start to improve over time. The person experiencing uncomplicated grief will begin to accept the loss and resume normal activities. Since the client is still unable to accept the loss after three years, this would not be classified as uncomplicated grief.

Choice C reason : Disenfranchised grief occurs when an individual's grief is not acknowledged or validated by society, often because the relationship to the deceased is not recognized, such as in the case of a pet or a distant relative. This type of grief is not typically associated with the duration of the grief but rather with the social context in which the grieving occurs.

Choice D reason : Anticipatory grief occurs before the actual loss, often in situations where a loved one is terminally ill. It involves grieving the impending loss and can include some of the same emotions as post-loss grief. Since the client's partner has already died, this would not be considered anticipatory grief.