In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:

Correct Answer: C

Rationale: Confronting the denial is the best response in this situation. Denial is a common defense mechanism that individuals may use when faced with overwhelming emotions or situations, such as in the case of a post-mastectomy client. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and accept their feelings, which is an important step in the healing and coping process. Ignoring or supporting the denial may hinder the client's ability to address their emotions and work through them effectively. Confronting the denial allows for open communication and helps the client move towards acceptance and adjustment.

Correct Answer: B

Rationale: Aling Iska's hemoglobin level of 11mg/dl and hematocrit level of 32% are both below the normal range for her age group. These low levels indicate anemia, which is a condition characterized by a decrease in the number of red blood cells or hemoglobin in the blood. Anemia can be caused by various factors, such as nutritional deficiencies (iron, vitamin B12, folate), chronic diseases, or bone marrow problems. In this case, given Aling Iska's advanced age of 78 years, it is essential for the nurse to conduct a thorough nutritional assessment to determine if her anemia is related to any deficiencies that can be addressed through dietary changes or supplementation. It is important to identify the underlying cause of anemia to provide appropriate interventions and prevent further complications.

Correct Answer: B

Rationale: Following hypophysectomy, which is the surgical removal of the pituitary gland, patients will require lifetime dependency on hormone replacement therapy. The pituitary gland plays a crucial role in regulating various hormones in the body, and without it, the body will not be able to produce essential hormones like growth hormone, thyroid-stimulating hormone, and others. Therefore, hormone replacement therapy is necessary to maintain hormone balance and prevent complications associated with hormone deficiencies. This major alteration in the patient's lifestyle necessitates ongoing medical management and monitoring to ensure hormone levels are maintained within a normal range. The other options (A, C, D) are not directly related to the necessary lifestyle changes following hypophysectomy.

Correct Answer: A

Rationale: Nutramigen is a hypoallergenic formula specifically designed for infants with cow's milk allergy (CMA). It is extensively hydrolyzed, which means the cow's milk proteins are broken down into smaller pieces, making it easier for babies with CMA to digest without triggering an allergic reaction. Other options such as goat's milk, Similac, and Enfamil are not suitable substitutes for an infant with CMA as they may still contain proteins that can cause an allergic response in these infants. Therefore, Nutramigen is the most appropriate recommendation for a 6-month-old infant diagnosed with cow's milk allergy.

Correct Answer: A

Rationale: Didanosine (ddl or Videx) is an antiretroviral medication used in the treatment of HIV/AIDS. However, one of the notable side effects of didanosine is peripheral neuropathy, which can manifest as tingling, numbness, or pain in the hands and feet. Since the client already has a history of peripheral neuropathy, prescribing didanosine may exacerbate this condition, making it important for the healthcare provider to exercise caution. Monitoring for any signs or symptoms of worsening peripheral neuropathy is essential in this case.