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 : Increase in basal metabolic rate.During NREM sleep, particularly in the deeper stages, the basal metabolic rate (BMR) actually decreases. This reduction in BMR is part of the restorative processes that occur during sleep, conserving energy for the body to use in repair and growth.

Choice B reason : Reduced secretion of growth hormones.Contrary to this statement, the secretion of growth hormones increases during NREM sleep, particularly during the deep stages (stage N3). These hormones play a crucial role in tissue growth and muscle repair.

Choice C reason : Decrease in body temperature.During NREM sleep, there is a decrease in body temperature as part of the body's thermoregulation process. This helps to conserve energy and is a characteristic physiological change during this phase of sleep.

Choice D reason : Constriction of peripheral blood vessels.Peripheral blood vessels do not typically constrict during NREM sleep. Instead, there is generally a decrease in sympathetic nervous system activity, which can lead to the dilation of blood vessels and a decrease in blood pressure.

Choice A reason : Rationalization is a defense mechanism where an individual justifies behaviors or feelings with plausible but inaccurate explanations to avoid confronting the true underlying motives or facts. In this scenario, the client is rationalizing their failure to take medication by blaming their partner's forgetfulness, rather than accepting personal responsibility for their health management.

Choice B reason : Projection involves attributing one's own unacceptable thoughts, feelings, or motives to another person. If the client had accused their partner of being irresponsible with medication as a reflection of their own behavior, it would be an example of projection. However, in this case, the client is not projecting their own forgetfulness onto their partner but rather shifting the blame.

Choice C reason : Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. It involves pushing uncomfortable thoughts or memories into the unconscious mind. The client's statement does not suggest they are unconsciously forgetting to take their medication; instead, they are consciously aware of their action and providing a justification for it.

Choice D reason : Regression is a return to earlier stages of development and abandoned forms of gratification belonging to them, prompted by dangers or conflicts arising at one of the later stages. A client demonstrating regression might exhibit childlike behaviors when faced with stress. The client's statement does not indicate a regression to more infantile behaviors or coping mechanisms.