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 : Sitting upright unsupported is a motor skill that typically develops after a baby has gained enough strength and balance, which usually occurs around 6 months of age. Before they can sit unsupported, infants need to develop control over their head and neck muscles, as well as their upper body strength.

Choice B reason : Standing while holding on to furniture, also known as cruising, is a skill that comes later in the first year of life, usually after the infant has mastered sitting and crawling. This skill is often seen around 9 to 12 months of age as the infant's leg and core muscles become strong enough to support their weight in an upright position.

Choice C reason : Transferring an object from hand to hand is a fine motor skill that develops as an infant's hand-eye coordination improves. This skill typically emerges around 4 to 6 months of age, after the infant has developed the ability to grasp objects and has begun to explore their environment more actively with their hands.

Choice D reason : Rolling from side to side is one of the first gross motor skills that infants develop, usually occurring around 2 to 4 months of age. This skill is an important precursor to more complex movements such as sitting, crawling, and walking. It begins with the infant learning to control their head movements and then progresses to rolling over from their stomach to their back and vice versa.

Choice A reason : Increasing intake of saturated fats is not recommended for reducing stress. Saturated fats can contribute to the development of heart disease by raising cholesterol levels and should be limited in a healthy diet.

Choice B reason : Limiting alcohol intake is generally a good practice, but specifying "3 drinks per day" is not accurate. The Dietary Guidelines for Americans recommend up to one drink per day for women and up to two drinks per day for men.

Choice C reason : Choosing complex carbohydrates each day is beneficial for managing stress. Complex carbohydrates can increase the amount of serotonin in the brain, which has a calming effect. Foods rich in complex carbohydrates include whole grains, fruits, vegetables, and legumes⁷.

Choice D reason : Consuming less than 2000 mg of sodium per day is part of a healthy diet, but it is not specifically related to stress reduction. The American Heart Association recommends no more than 2300 mg a day and moving toward an ideal limit of no more than 1500 mg per day for most adults.