A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:
"I'll make sure I stay away from microwave ovens." This statement is incorrect . While there were concerns about interference in the past, modern pacemakers are generally not affected by household appliances like microwave ovens.
Choice B Reason:
"I should have an MRI, rather than a CAT scan, if necessary." This statement is incorrect. Both MRI and CAT scans have considerations when a person has a pacemaker. An MRI might be contraindicated due to the magnetic field, while a CAT scan might be a safer imaging choice.
Choice C Reason:
"I'll hold my cell phone against the ear on the opposite side of my body." This statement reflects an understanding of the precaution to avoid holding a cell phone directly over the implanted pacemaker. Keeping the phone on the opposite side helps minimize the potential interference with the pacemaker's function.
Choice D Reason:
"I shouldn't travel by plane because of airport security." This statement is incorrect. Airport security systems generally don't affect pacemakers, so traveling by plane is usually safe. However, informing security personnel about the presence of a pacemaker is a good practice.

Choice A Reason:

Leave the television on in the client's room is incorrect. Leaving the television on doesn't directly address the safety concern of falls. While it might provide some distraction or comfort, it doesn't mitigate the risk of the client attempting to leave the bed unsafely.

Choice B Reason:

Raise all four side rails while the client is in bed is incorrect. Using all four side rails can be considered a form of restraint and is generally not recommended due to the risk of entrapment and potential psychological distress for the client. It can also increase the risk of agitation and attempts to climb over the rails, potentially resulting in falls.

Choice C Reason:

Move the overbed table away from the bed is incorrect. Moving the overbed table might reduce clutter around the bed area, but it doesn't directly address the risk of falls for a client with dementia. It's more about optimizing the environment than specifically addressing the safety concern related to the client's condition.

Choice D Reason:

Apply a motion sensor mat to the client's bed is correct. For an older adult with dementia at risk for falls, a motion sensor mat can be an effective safety measure. It alerts the staff when the client attempts to get out of bed, allowing for timely intervention to prevent falls. This helps the nursing staff respond promptly, ensuring the client's safety.