A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Choice A reason: The correct answer is a because refusing to look at the dressing or surgical incision can indicate that the client is having difficulty accepting the loss of her breast. This behavior may suggest that the client is struggling with body image issues, grief, or denial about the changes to her body.

Choice B reason: Requesting pain medication every 3 hours is a common postoperative behavior to manage pain and does not necessarily indicate difficulty adjusting to the loss of a breast. Pain management is a normal part of recovery.

Choice C reason: Asking questions about the information on the postoperative care pamphlet demonstrates an interest in understanding and managing her care. This behavior indicates that the client is engaged in her recovery process, rather than struggling to adjust.

Choice D reason: Performing arm exercises once or twice each day shows that the client is following postoperative care instructions and is actively participating in her rehabilitation. This behavior does not suggest difficulty adjusting to the loss of her breast.

Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.

Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.

Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.

Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.