Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is:
A. Correct illumination of the environment
B. Amount of regular exercise
C. The resting pulse rate
D. Status of salt intake
Correct Answer: A. Correct illumination of the environment
To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Providing lighting in key places can reduce fall risk and avoid obstacles during mobility. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate.
Option B: Exercises can improve muscle strength, balance, coordination, and reaction time. Physical conditioning reduces the incidence of falls and avoids injury that is sustained when a fall happens. However, the amount of regular exercise is not the most important factor to assess. It is only indirectly related.
Option C: The resting pulse rate is not related to preventing falls. Instead, place assistive devices and commonly use items within reach. This provides easy access to assistive devices and personal care items. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
Option D: The salt intake is not directly related to preventing falls. Instead, advise the client to wear shoes or slippers with non-slip soles when walking. Wearing non-slip footwear helps prevent slips and falls.