A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

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.

Rationale for Correct Choices:

• Self-harm: The client expresses suicidal ideation influenced by delusions, indicating a strong risk of acting on these impulses. In schizophrenia, command hallucinations are particularly dangerous when they involve instructions to harm oneself.
• Command hallucinations: The client reports hearing voices directing them to act, which is a hallmark of command hallucinations. These are associated with a heightened risk of harm to self or others, especially when the client appears fearful or paranoid, as in this case.

Rationale for Incorrect Choices:

• Palming medications: Although the client is suspicious and refuses medication (“I’m not letting you poison me”), there is no evidence yet of palming or hiding pills. The agitation could indicate refusal, but not covert medication avoidance.
• Poor hygiene: While the client shows confusion regarding bathing and clothing, these are not the most immediate safety threats compared to suicide risk. Poor hygiene is a concern in schizophrenia but not the most critical issue at this time.
• Impaired memory: Impaired memory is evident (e.g., forgetting routines), but this is not directly linked to a life-threatening risk. Memory issues can affect functioning but don’t explain the urgency of the client’s safety threat.
• Distractibility: The client appears distracted at times (e.g., during dressing), but distractibility alone does not account for the risk of self-harm. It contributes to disorganization but is not the main safety concern.