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 : Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. While the causes of ADHD are not fully understood, current research does not establish childhood obesity as a direct risk factor for developing ADHD. ADHD is thought to be linked to genetic factors and certain environmental exposures during pregnancy.

Choice B reason : Hypotension, or low blood pressure, is generally not associated with childhood obesity. In fact, obesity, especially in the long term, is more commonly linked to hypertension (high blood pressure) due to increased strain on the heart and blood vessels, and not hypotension.

Choice C reason : Rheumatoid arthritis is an autoimmune condition that causes joint inflammation and damage. It is not typically considered a direct complication of childhood obesity. While obesity can contribute to joint problems due to increased mechanical stress, it is not a known cause of autoimmune conditions like rheumatoid arthritis.

Choice D reason : Diabetes mellitus, particularly type 2 diabetes, is a well-documented potential complication of childhood obesity. Obesity increases the risk of developing insulin resistance, which can lead to elevated blood sugar levels and eventually type 2 diabetes. The excess fat, particularly visceral fat, is associated with chronic inflammation and metabolic changes that contribute to the development of diabetes⁴.

Choice A reason : The term "alert" is an objective finding in the nursing assessment. It refers to the client's level of consciousness and responsiveness to stimuli, which can be directly observed and measured by the nurse during the evaluation. Being alert is a state that is evident through the client's behavior, responses, and interactions.

Choice B reason : "Pacing" is an objective finding. It is a visible behavior that can be observed and documented by the nurse without the need for interpretation or reliance on what the client says. Pacing can be quantified by the number of times the client walks back and forth in a given period.

Choice C reason : "Anxiety" is a subjective finding because it is based on the client's personal feelings and cannot be directly observed or measured by the nurse. It is reported by the client and requires the nurse to rely on the client's expression of their emotional state.

Choice D reason : "Restless" is an objective finding. Restlessness can be observed as physical movements, such as the inability to stay still, fidgeting, or frequent changes in position. These are behaviors that the nurse can see and document.