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) Diaphoresis:
While diaphoresis (excessive sweating) may occur with some cardiac or respiratory conditions, it is not a primary or expected sign of circulatory overload. Circulatory overload generally involves fluid accumulation in the body, and symptoms are more likely related to fluid retention and increased workload on the heart rather than sweating.

B) Weight loss:
Weight loss is not typically associated with circulatory overload. In fact, one of the hallmark signs of circulatory overload is weight gain due to fluid retention. The body retains excess fluid in the vascular system, leading to an increase in weight rather than weight loss.

C) Hypotension:
Hypotension (low blood pressure) is generally not associated with circulatory overload. Circulatory overload typically results in elevated blood pressure due to the increased volume of circulating fluid. In some cases, if the heart is unable to handle the increased volume, symptoms like pulmonary edema or shortness of breath can occur, but hypotension is more commonly seen in conditions like shock or severe fluid loss.

D) Tachycardia:
Tachycardia (an elevated heart rate) is a common finding in circulatory overload. When there is an excess of fluid in the body, the heart has to work harder to pump the additional volume of blood, leading to an increased heart rate. This is a compensatory response to the increased workload on the heart. It is also a sign that the body is attempting to maintain adequate tissue perfusion despite the excess fluid volume.

A) Planning:
The step of the nursing process where the nurse formulates goals to address an identified problem is planning. In this phase, the nurse develops a care plan by setting measurable and achievable goals based on the assessment data. These goals are designed to address the specific health problems identified during the assessment phase. The planning stage also involves determining appropriate interventions and establishing expected outcomes for the patient. It's critical to ensure that the goals are realistic and aligned with the patient’s needs and preferences.

B) Implementation:
Implementation refers to the actual carrying out of the nursing interventions and care plan that were developed during the planning phase. This is when the nurse takes action based on the goals set earlier, such as administering medications, teaching the patient, or performing specific procedures. While this phase is crucial for the success of the care plan, it does not involve the creation of goals, which is the focus of the planning phase.

C) Assessment:
Assessment is the first step in the nursing process. It involves gathering comprehensive information about the patient’s physical, psychological, social, and emotional status. The assessment phase is focused on identifying the patient’s needs, strengths, and problems. While it provides the foundation for formulating goals, it is not the phase where goals are set. Instead, the assessment phase is about collecting data to inform the planning process.
D) Evaluation:
Evaluation occurs after the implementation of interventions. During this phase, the nurse evaluates whether the patient’s goals have been met, partially met, or not met at all. The nurse examines the effectiveness of the care plan and determines if adjustments need to be made. This is not the phase where goals are set; rather, it is a reflective stage where the nurse assesses progress toward achieving the goals established in the planning phase.