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 : Rationalization is a defense mechanism where an individual justifies behaviors or feelings with plausible but inaccurate explanations to avoid confronting the true underlying motives or facts. In this scenario, the client is rationalizing their failure to take medication by blaming their partner's forgetfulness, rather than accepting personal responsibility for their health management.

Choice B reason : Projection involves attributing one's own unacceptable thoughts, feelings, or motives to another person. If the client had accused their partner of being irresponsible with medication as a reflection of their own behavior, it would be an example of projection. However, in this case, the client is not projecting their own forgetfulness onto their partner but rather shifting the blame.

Choice C reason : Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. It involves pushing uncomfortable thoughts or memories into the unconscious mind. The client's statement does not suggest they are unconsciously forgetting to take their medication; instead, they are consciously aware of their action and providing a justification for it.

Choice D reason : Regression is a return to earlier stages of development and abandoned forms of gratification belonging to them, prompted by dangers or conflicts arising at one of the later stages. A client demonstrating regression might exhibit childlike behaviors when faced with stress. The client's statement does not indicate a regression to more infantile behaviors or coping mechanisms.

Choice A reason : Dry mouth, also known as xerostomia, is a common side effect of diphenhydramine, an antihistamine used to treat insomnia among other conditions. It occurs because diphenhydramine has anticholinergic properties, which means it inhibits the action of the neurotransmitter acetylcholine. This inhibition can reduce saliva production, leading to a feeling of dryness in the mouth.

Choice B reason : Hypertension, or high blood pressure, is not a typical side effect of diphenhydramine. While some medications, particularly decongestants, can raise blood pressure, diphenhydramine does not usually have this effect. However, individuals with pre-existing heart conditions should consult a healthcare provider before using it.

Choice C reason : Memory loss is not commonly listed as a side effect of diphenhydramine. However, because it can cause drowsiness and has sedative effects, it may lead to temporary forgetfulness or confusion, especially in older adults or when taken in higher doses.

Choice D reason : 'Medications' is not an adverse reaction but rather a general term for drugs used to diagnose, treat, or prevent illness. In the context of diphenhydramine, it would be more appropriate to discuss specific side effects or adverse reactions related to its use.