A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

A) A client who has heart failure and peripheral edema:
While heart failure and peripheral edema are significant conditions that require medical attention, they are chronic issues that, in most cases, are not immediately life-threatening in an emergency department setting unless there is acute decompensated heart failure or signs of severe fluid overload or respiratory distress.

B) A client who reports urinary burning and a temperature of 29.2° C (102.5°F):
This client is febrile, which suggests an infection, possibly a urinary tract infection (UTI). Although fever and urinary burning are concerning, infection-related fevers generally don't pose an immediate life threat unless there is sepsis or severe systemic involvement. A temperature of 102.5°F is significant, but the client's condition is not as urgent as other life-threatening emergencies like an arrhythmia or severe cardiovascular instability.

C) A client who has cirrhosis of the liver and bruising on their arms:
Bruising in a client with cirrhosis of the liver could indicate bleeding tendencies, which is an important concern. However, unless there is active bleeding or signs of severe liver failure (e.g., confusion, ascites, jaundice), this is not an immediate, life-threatening situation.

D) A client who has a new onset of atrial fibrillation and a heart rate of 152/min:
A new onset of atrial fibrillation (AF) with a heart rate of 152/min is an immediate priority. This is a life-threatening arrhythmia that can lead to decreased cardiac output, risk of stroke, and hemodynamic instability. A heart rate of 152 beats per minute is dangerously high, which could lead to tachycardia-induced cardiomyopathy or cardiogenic shock. Immediate intervention is needed to manage the arrhythmia and prevent further complications.

A) The client reports dizziness when ambulating to the bathroom:
Dizziness upon ambulation is a key indicator that the client may be experiencing orthostatic hypotension, a potential side effect of antihypertensive medications. If the client is already experiencing dizziness, this could be exacerbated by administering the medication, which may cause a further drop in blood pressure. It is crucial for the nurse to further assess the client’s blood pressure (particularly orthostatic blood pressure readings) and overall clinical status before administering the medication to prevent potential falls, injury, or worsening hypotension.

B) The client reports having trouble sleeping the previous night:
While difficulty sleeping could be a concern, it is not directly related to the administration of an antihypertensive medication unless the client reports other symptoms, such as palpitations, chest pain, or anxiety, which may indicate an underlying issue. It is not a priority to delay or further assess medication administration based solely on sleep disturbances unless other significant factors are present.

C) The client ate 60% of their breakfast:
Eating 60% of the meal is not typically a reason to withhold or delay antihypertensive medication unless the client is showing signs of severe nausea, vomiting, or gastrointestinal distress. Many antihypertensive medications can be taken with food to reduce gastric irritation, and this percentage of food intake does not pose an immediate concern.

D) The client has a urine output of 400 mL for the past 8 hours:
Urine output of 400 mL over 8 hours is within the normal range (approximately 50–60 mL/hr), suggesting adequate renal function and fluid balance. While a decrease in urine output can be concerning, there is no immediate indication that this level of output would interfere with the administration of an antihypertensive medication.