A nurse is caring for a client who has fluid volume excess. Which of the following manifestations should the nurse expect?

Rationale

A. A middle adult experiences physical changes: Physical changes such as menopause or decreased strength are normal developmental events and do not necessarily indicate a change in the family system. These are expected life transitions rather than stressor-induced changes in family roles.

B. A young adult develops a close, personal relationship: Forming intimate relationships is part of normal young adult development and does not, by itself, indicate a disruption or change in family dynamics. It is a typical milestone rather than a stressor affecting the family system.

C. A middle adult assumes their parent's responsibilities: Taking on parental responsibilities, such as caring for aging parents, reflects a significant role shift within the family system. This role reversal can create stress, alter family dynamics, and indicate a response to external or internal stressors affecting the family structure.

D. A young adult focuses on their career: Career development is a normal developmental task for young adults and does not inherently signal a change in family roles or system dynamics. It reflects personal growth and independence rather than stress-related change in family functioning.

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.