A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Rationale:

A. Cheyne-Stokes respirations: This irregular breathing pattern is common in clients nearing end of life due to neurologic decline. It is not a direct indicator of pain and does not necessarily require pain medication unless associated with distress.

B. Restlessness: Restlessness in a palliative care client often signals unrelieved pain, discomfort, or anxiety. It is a nonverbal cue frequently observed in clients unable to communicate pain and should prompt consideration of analgesia.

C. Mottled skin: Mottling is a sign of reduced perfusion and impending death. It reflects circulatory changes but does not directly indicate pain or warrant pain medication unless accompanied by other signs of distress.

D. Constricted pupils: Pupil constriction may result from certain medications (e.g., opioids) or brainstem pressure but is not a reliable sign of pain. It does not, by itself, indicate a need for analgesic intervention.

Rationale:

A. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed alters body mechanics and may complicate the transfer by increasing the angle of elevation, which can lead to strain or improper alignment during the move.

B. Use a pillow underneath the client's head when repositioning a client in bed: A pillow can aid in comfort but does not contribute to safe body mechanics during repositioning. It may also interfere with alignment or reduce the ability to properly lift or turn the client.

C. Transfer on the client's weaker side when moving a client from a bed to a chair: Transferring toward the weaker side increases the risk of instability and falls. Safe ergonomic practice involves moving clients toward their stronger side to encourage participation and minimize staff effort.

D. Use a lateral transfer device when moving a client from a bed to a stretcher: Lateral transfer devices reduce friction between surfaces, making it easier to move the client without excessive force. This protects both the client and the nurse from musculoskeletal injuries and supports safe practice.