A nurse is caring for a client who has dehydration and reports muscle cramps and constipation. Which of the following laboratory values should the nurse expect?

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.

Rationale

A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.

B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.

C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.

D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.