The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

A. Use of resistance bands
Explanation: Resistance band exercises can improve strength and flexibility, but they may not specifically address balance as directly as Tai Chi or certain yoga poses.

B. Stretching
Explanation: Stretching exercises contribute to flexibility and can be part of a well-rounded exercise routine. While they can be beneficial, other exercises like Tai Chi and yoga may have a more specific focus on balance improvement.

C. Tai Chi
Explanation: Tai Chi is a low-impact exercise that emphasizes slow, controlled movements, weight shifting, and mindfulness. It has been shown to improve balance and reduce the risk of falls, making it suitable for individuals at high risk.

D. Yoga
Explanation: Yoga incorporates balance, flexibility, and strength exercises. Certain yoga poses can help improve balance and stability, making it beneficial for individuals at risk for falls.

E. Range of Motion (ROM) activities
Explanation: Range of motion activities helps maintain joint flexibility and can contribute to improved balance. Encouraging the client to perform gentle range of motion exercises can be beneficial.

A. Assist with obtaining informed consent from the client.
Explanation: Informed consent is a critical aspect of healthcare procedures, but it requires the patient to have the capacity to understand and make decisions. In this scenario, the client is intubated and on mechanical ventilation, which might compromise their ability to communicate effectively. If the client lacks capacity, obtaining consent from the durable power of attorney (POA) is more appropriate.

B. Refer to the client's advance directive for a name.
Explanation: Advance directives, including the durable POA, provide guidance on a person's wishes for healthcare decisions when they are unable to communicate. However, the advance directive may not always specify a particular person's name for decisions related to specific medical interventions. The key consideration in this situation is to determine the current decision-making capacity and involve the appropriate decision-maker if needed.

C. Determine the client's inability to make reasonable decisions.
Explanation: This is the correct answer. In this scenario, the nurse should assess the client's capacity to make decisions. If the client lacks capacity, the durable POA can be activated to make healthcare decisions on behalf of the client. Capacity involves the ability to understand relevant information, appreciate the consequences of decisions, and communicate a choice.

D. Use the oral trail-making test to measure cognitive function.
Explanation: The oral trail-making test is a cognitive screening tool, but it may not be suitable in this critical care scenario with an intubated and mechanically ventilated patient. Moreover, the primary concern in this situation is determining the capacity to make healthcare decisions, which requires a more comprehensive evaluation than a specific cognitive function test. The focus should be on decision-making capacity rather than a cognitive assessment.