A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

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.

Choice A Reason:

The client had a hemorrhoidectomy 1 year ago is appropriate. While hemorrhoids involve bleeding in the anal area, the blood from hemorrhoids is usually visibly present and not considered "occult" or hidden. A history of hemorrhoidectomy is less likely to cause a false-positive occult blood test result as the bleeding is typically visible.

Choice B Reason:

The client takes ibuprofen for headaches is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can irritate the gastrointestinal tract, leading to small amounts of bleeding. This bleeding, although not typically visible, can be detected by occult blood tests, resulting in a false-positive result

Choice C Reason:

The client has a history of breast cancer is incorrect. A history of breast cancer, in itself, is not directly related to gastrointestinal bleeding that would lead to a false-positive result in an occult blood test. Occult blood screening tests primarily detect bleeding from the gastrointestinal tract.

Choice D Reason:

The client consumed citrus juice 3 days before the test is incorrect. Consumption of citrus juice is not known to cause false-positive results in occult blood screening tests. These tests are designed to detect blood specifically from the gastrointestinal tract and aren't affected by citrus juice consumption.