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. "As the health care proxy, you are the one who makes the decisions. Let's call your mom's doctor."
Explanation: This response inaccurately suggests that the health care proxy has the authority to make decisions even when the client has decision-making capacity. The focus should be on the client's autonomy.

B. "I understand why you are so upset. I don't think she is doing the right thing either. Let us think together how we can change her mind."
Explanation: This response is inappropriate as it involves the nurse expressing a personal opinion and attempting to influence the client's decision. The nurse's role is to support the client's autonomy and facilitate communication between the client and their family.

C. "You will need to go to court and be declared a guardian."
Explanation: Involving the court and seeking guardianship is not warranted when the client has decision-making capacity. This option is not aligned with the principles of respecting the client's autonomy and decision-making capacity.

D. "Health care proxies only come into play when the individual can no longer make their own decisions. Your mother is able to make her own decisions. I suggest you talk with her."
Explanation: In this scenario, the client is cognitively intact and has decision-making capacity. As long as the older adult is able to make their own decisions, the health care proxy's role is not activated. The nurse appropriately advises the daughter to communicate directly with her mother about her concerns and decisions. This respects the autonomy of the client, who has the right to make decisions about their own healthcare as long as they have the capacity to do so.

A. He is able to name objects with which he comes in contact correctly.

Explanation: Being able to name objects correctly indicates intact language and object recognition skills, which are positive aspects of cognitive function.

B. He is constantly checking to see whether what he did is correct.

Explanation: Constantly checking to see whether what he did is correct may be an indicator of anxiety or uncertainty about cognitive performance. While this behavior alone does not confirm cognitive impairment, it raises a question about the individual's confidence or potential challenges in decision-making.

C. He is able to hold a conversation with you.

Explanation: Holding a conversation demonstrates language and communication abilities, suggesting intact cognitive skills for social interaction.

D. His attention span will last as long as the project he is working on.

Explanation: Having an attention span that matches the duration of a project suggests a focused and goal-oriented approach, which can be a positive aspect of cognitive function.