A nurse is caring for a client on a medical-surgical unit. Which of the following actions should the nurse take to maintain the client's confidentiality?

Rationale

A. Apply a transfer belt to the client prior to transferring to the stretcher: Transfer belts are used for clients who can stand or provide some degree of weight-bearing support. An immobile 104.3-kg client cannot safely assist with the transfer, making the belt ineffective and unsafe. Using a transfer belt in this scenario increases the risk of falls and caregiver injury.

B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board reduces friction and allows the client to be moved laterally as a single unit, which is the safest method for an immobile client of this weight. Using at least two trained staff members prevents strain and ensures coordinated movement.

C. Have the client roll onto a transfer board and pull the board onto the stretcher: This technique requires the client to participate by rolling, which is not feasible for someone who is immobile. Pulling a transfer board with the client on it creates unnecessary shear forces that increase the risk of skin breakdown. This approach is neither safe nor appropriate for a heavy, immobile patient.

D. Move the client's upper body onto the stretcher first: Moving the client unevenly in sections can cause spinal misalignment and increases the risk of caregiver injury due to poor body mechanics. This technique also creates friction on the client’s skin and may cause discomfort or tissue injury. A coordinated lateral transfer keeps the body aligned and is recommended.

Rationale

A. Sublimation: Sublimation involves channeling unacceptable impulses into socially acceptable or constructive activities, such as exercising or creating art. Smoking to manage anxiety does not transform the impulse into a positive behavior, so this does not fit.

B. Projection: Projection occurs when an individual attributes their own unacceptable feelings or impulses onto someone else. The client is not blaming others for their anxiety or behavior, so projection is not demonstrated here.

C. Rationalization: Rationalization involves justifying behaviors with seemingly logical reasons to avoid confronting the true underlying feelings. The client explains smoking as a way to manage anxiety, providing a rational explanation for a behavior that may have deeper psychological or habitual roots.

D. Dissociation: Dissociation involves disconnecting from reality or separating oneself from thoughts, feelings, or identity. The client remains aware of their behavior and feelings, so dissociation is not applicable in this scenario.