A nurse is caring for a client who has hepatic encephalopathy. Which of the following laboratory values should the nurse monitor?

Rationale:

A. Conversion: Conversion involves the expression of psychological stress through physical symptoms without an underlying medical cause. The client is describing real pain rather than expressing a psychological conflict as a physical symptom, so this does not match conversion.

B. Displacement: Displacement occurs when a person redirects emotions or feelings from the original source to a safer target. The client is addressing the nurse directly about pain management, not redirecting feelings onto another target, so this is not displacement.

C. Introjection: Introjection involves internalizing the beliefs or values of another person. The client is expressing frustration about pain management rather than adopting someone else’s values or attitudes, so introjection does not apply here.

D. Projection: Projection occurs when a person attributes their own feelings, motives, or thoughts onto someone else. In this case, the client is suggesting that the nurse does not believe them, which reflects the client projecting their feelings of frustration and mistrust onto the nurse.

Rationale:

A. Encourage the client to drink 3000 mL of fluid daily: The client has heart failure with a prescribed fluid restriction of 1000 mL/day. Encouraging excess fluid intake could worsen fluid overload and pulmonary edema, so this is not appropriate.

B. Use soap and water to provide perineal care: Proper perineal hygiene with soap and water reduces the risk of introducing bacteria into the urinary tract, helping prevent catheter-associated urinary tract infections (CAUTIs).

C. Place the drainage bag on the bed when transporting the client: The drainage bag should always be kept below the level of the bladder to prevent backflow and contamination. Placing it on the bed increases the risk of infection and is contraindicated.

D. Change the indwelling urinary catheter tubing every 3 days: Routine changing of the catheter tubing is not recommended as it can increase the risk of infection. Tubing should only be changed if it is compromised, soiled, or obstructed.

E. Empty the drainage bag when it is half-full: Regularly emptying the drainage bag before it becomes overly full prevents backflow and reduces bacterial proliferation, helping to decrease UTI risk.

F. Review the need for the indwelling urinary catheter daily: Assessing the ongoing need for the catheter allows for timely removal, which is the single most effective intervention to prevent catheter-associated urinary tract infections.