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.

A. Glaucoma typically affects peripheral vision first and may lead to tunnel vision as the disease progresses. While it can cause significant vision loss, it is not primarily characterized by a decrease in central vision.
B. Macular degeneration specifically affects the central part of the retina (the macula), leading to a loss of central vision while peripheral vision remains intact. It is the most common cause of vision loss in older adults and directly correlates with the symptom described.
C. Diabetic retinopathy primarily affects the blood vessels in the retina and can lead to various vision problems, including blurred vision, floaters, and even blindness. However, it does not exclusively cause a decrease in central vision; it often affects both central and peripheral vision.
D. Cataracts typically cause cloudy or blurred vision but do not specifically lead to a decrease in central vision alone. They may affect overall vision clarity, including both central and peripheral vision, but the primary symptom is a general haziness rather than a focused loss of central vision.

A. While changes in vital signs, such as increased heart rate and blood pressure, may indicate pain, they are not specific to pain and can be influenced by other factors.
B. The type of surgery can provide some clues about the potential for pain, but it does not accurately reflect the individual's pain experience.
C. Nonverbal cues like grimacing, guarding, or restlessness can suggest pain, but they are not always reliable indicators. Some clients may not exhibit obvious signs of pain, even if they are experiencing significant discomfort.
D. This is the most reliable source of information about a client's pain intensity. Only the client can accurately describe their own pain experience, including its location, severity, and quality.