NURSINGTB.COM Chapter 54: Nursing Management: Breast Disorders Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. The nurse is teaching a client about breast self-examination (BSE) who has had a right-sided mastectomy. Which of the following information should the nurse include in the teaching plan? a. Only the remaining breast requires a mammogram screening annually. b. BSE should be done daily while taking a bath or shower. c. Mammograms should be scheduled every two years. d. Performing BSE monthly ANS: D It is recommended, postmastectomy, that the client perform monthly BSE on the remaining breast and the surgical site. The most common site of local recurrence of breast cancer is at the surgical site. The woman should undergo appropriate breast imaging at regular intervals (usually 6 months to 1 year), as determined by her risk of recurrence and breast cancer history. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 2. To determine the risk for breast cancer in a client who has found a small lump in the left breast, which of the following questions is most pertinent for the nurse to ask? a. “Do you currently smoke cigarettes?” b. “Have you ever had any breast injuries?” c. “At what age did you start having menstrual periods?” d. “Is there any family history of fibrocystic breast changes?” ANS: C Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 3. The nurse is preparing a client with a small immobile breast lump for a fine-needle aspiration (FNA) biopsy. Which of the following information about the procedure should the nurse explain to the client? a. FNA is done in the outpatient clinic, and results are available in 1–2 days. b. Only a small incision is needed, resulting in minimal breast pain and scarring. c. If the biopsy results are negative, no further diagnostic testing will be needed. d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion. ANS: A FNA is done in outpatient settings, and results are available in 24–48 hours. No incision is needed. FNA may be guided by ultrasound, but not by mammogram. Since the immobility of the breast lump suggests cancer, further testing will be done if the FNA is negative. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM 4. The nurse is conducting a breast assessment on a female client. Which of the following findings is most indicative of a need for further evaluation? a. Bilateral nodules that are tender with palpation b. A nodule that is 1 cm in size, painless, and firm c. A lump that increases in size before the menstrual period d. A lump that is small, mobile, and has a rubbery consistency ANS: B Painless and fixed lumps suggest breast cancer; a nodule that is 1 cm in size, firm, and painless suggests breast cancer. The other findings are more suggestive of benign processes such as fibrocystic breasts and fibroadenoma. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 5. The nurse is caring for a client who is at menopause and considering the use of hormone replacement therapy (HRT) but is concerned about the risk of breast cancer. Which of the following information should the nurse include when discussing HRT with the client? a. HRT does not appear to increase the risk for breast cancer unless there are other risk factors. b. HRT is a safe therapy for menopausal symptoms if there is no family history of BRCA genes. c. She and her health care provider must weigh the benefits of HRT against the possible risks of breast cancer. d. Alternative therapies with herbs and natural drugs are as effective as estrogen in relieving menopausal symptoms. ANS: C Because HRT has been linked to increased risk for breast cancer, the client and provider must determine whether or not to use HRT. Breast cancer incidence is increased in women using HRT, independent of other risk factors. HRT increases the risk for both non-BRCA-associated cancer and BRCA-related cancers. Alternative therapies can be used but are not consistent in relieving menopausal symptoms. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 6. A client with stage II breast cancer tells the nurse, “I need to decide about what type of surgery to have, but I feel so overwhelmed that I cannot make any decisions yet! What do you think I should do?” Which of the following responses by the nurse is best? a. “I would have a lumpectomy, but you need to decide what is best for you.” b. “Tell me what you understand about the surgical options that are available.” c. “It would not be appropriate for me to make the decision about your health.” d. “There is no need to make a decision rapidly; you have time to think about this.” ANS: B NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM This response indicates the nurse’s willingness to assist the client with the decision-making process without imposing the nurse’s values or opinions. It is not appropriate to say that it is not the nurse’s decision to make as this would close the conversation and indicates that the nurse is not willing to help the client with the decision about treatment. Because treatment decisions for breast cancer do need to be made relatively quickly, it is not alright to tell the client that the decision does not need to be made rapidly. Since the nurse’s values and situation are not the same as the client’s, imposing the nurse’s opinions during this emotionally vulnerable time is not appropriate. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 7. The nurse is assessing a client at the clinic who has metastatic breast cancer and has a new prescription for trastuzumab. Which of the following findings is a reason for the administration of this medication? a. Allergic to iodine b. HER-2 positive c. Immune to tamoxifen d. Severely dehydrated ANS: B For clients who are HER-2 positive, trastuzumab is a monoclonal antibody to HER-2. After the antibody attaches to the antigen, it is taken into the cancer cells and eventually kills them. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 8. The pathology report for a client who has had a modified radical mastectomy identifies the tumour as an estrogen-receptor positive adenocarcinoma. Which of the following medications should the nurse include when teaching the client? a. Estradiol b. Raloxifene c. Tamoxifen d. Trastuzumab ANS: C Tamoxifen is used for estrogen-dependent breast tumours in premenopausal women. Raloxifene is used to prevent breast cancer, but it is not used postmastectomy to treat breast cancer. Estradiol will increase the growth of estrogen-dependent tumours. Trastuzumab is used to treat tumours that have the HER-2 receptor. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 9. The nurse is caring for a client who returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. Which of the following nursing actions should be included in the plan of care? a. Insist that the client examine the surgical incision when the dressings are removed. b. Teach the client to use the ordered patient-controlled analgesia (PCA) every 10 minutes. c. Post a sign at the bedside warning against blood pressures or venipunctures in the right arm. d. Obtain a permanent breast prosthesis for the client before she is discharged from the hospital. NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM ANS: C The client is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The client is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the client to examine the incision and participate in care when the client feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 10. The nurse is caring for a client who has had a right mastectomy and the client asks the nurse how long the biannual mammography will have to continue. Which of the following time frames should the nurse inform the client is recommended for mammography postmastectomy? a. Every 6 months for a year b. Every 6 months for 2 years c. Every 6 months for 5 years d. Every 6 months for life ANS: B The client should undergo appropriate breast imaging at regular intervals (usually 6 months to 1 year) for two consecutive years. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 11. A client has a saline breast implant inserted in the outpatient surgery area. Which of the following instructions should the nurse include in the discharge teaching? a. Take Aspirin every 4 hours to reduce inflammation. b. Check wound drains for excessive blood or any foul odour. c. Wear a loose-fitting bra to decrease irritation of the sutures. d. Resume normal activities 2–3 days after the mammoplasty. ANS: B The client should be taught drain care because the drains will be in place for 2 or 3 days after surgery. Normal activities can be resumed after 2–3 weeks. A bra that provides good support is typically ordered. Aspirin will decrease coagulation and is typically not given after surgery. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 12. Which of the following information should the nurse include when teaching a client about the transverse rectus abdominis musculo-cutaneous (TRAM) procedure? a. Saline-filled implants are placed under the pectoral muscles. b. Recovery from the TRAM surgery takes at least 6–8 weeks. c. Muscle tissue is removed from the back and used to form a breast. d. TRAM flap procedures may be done in outpatient surgery centres. ANS: B Clients take at least 6–8 weeks to recover from the TRAM surgery. Tissue from the abdomen is used to reconstruct the breast. The TRAM procedure can take up to 8 hours and requires postoperative hospitalization. Saline implants are used in mammoplasty. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM 13. Which of the following statements by a client newly diagnosed with stage I breast cancer indicates to the nurse that client teaching may be needed? a. “There are several options available for treating the cancer.” b. “I will probably need radiation to the breast after having the surgery.” c. “I can probably have reconstructive surgery at the same time as a mastectomy.” d. “Mastectomy will be the best choice to decrease the chance of cancer recurrence.” ANS: D The survival rates with lumpectomy and radiation or modified radical mastectomy are comparable. The other client statements indicate a good understanding of stage I breast cancer treatment. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 14. The nurse is caring for a client who is scheduled for stereotactic core biopsy of the breast. Which of the following information should the nurse include in client education? a. A local anaesthetic will be given before the biopsy specimen is obtained. b. You will need to lie flat on your back and lie very still during the biopsy. c. A thin needle will be inserted into the lump and aspirated to remove tissue. d. You should not have anything to eat or drink for 6 hours before the procedure. ANS: A A local anaesthetic is given before stereotactic biopsy. NPO status is not needed because no sedative drugs are given. The client is placed in the prone position. A biopsy gun is used to obtain the specimens. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 15. A student nurse prepares a list of teaching topics for a client with a new diagnosis of breast cancer. Which of the following topics indicate that the student needs more education about breast cancer diagnostic testing? a. A firm, moveable mass is most often breast cancer b. HER-2 receptor testing c. Estrogen receptor testing d. Oncotype DX assay testing ANS: A A firm, moveable mass is characteristic of fibroadenoma, not breast cancer. The other tests are likely to be used for additional diagnostic testing in a client with breast cancer. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 16. After a client is diagnosed with lobular carcinoma in situ (LCIS), the nurse will anticipate that client teaching may be needed about which of the following topics? a. Lumpectomy b. Lymphatic mapping c. MammaPrint testing d. Tamoxifen ANS: D NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM Tamoxifen is used as a chemopreventive therapy in some clients with LCIS. The other diagnostic tests and therapies are not needed because LCIS does not usually require treatment. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 17. The nurse is caring for a client following breast augmentation surgery. Which of the following information should the nurse include in client teaching? a. A drain will be in place for 24 hours after the surgery and then removed. b. Temperature will be monitored every 4 hours postoperatively. c. A compression dressing will be in place for 5–7 days d. Most women can resume normal activities 1 week post-op. ANS: B The client’s temperature should be monitored. Breast augmentation clients have drains in place in the surgical site to prevent hematoma formation and then removed 2–3 days after surgery or when drainage is less than 20–30 mL/day. The drainage must be examined for colour and odour to detect postoperative infection or hemorrhage. A compression dressing is not kept in place for 5–7 days; dressings should be changed as necessary with sterile technique, and prescribed. Depending on the extent of the operation, most women can resume normal activities within 2–3 weeks. Strenuous exercise may not be appropriate until several weeks later. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 18. The nurse has completed teaching a client who has breast cancer about the newly prescribed tamoxifen. Which of the following client statements indicate that the teaching has been effective? a. “I will expect to have leg cramps with this drug.” b. “I will call the clinic if I develop any hot flashes.” c. “I will be taking the medication for at least a year.” d. “I will call immediately if I experience cloudy and blurred vision.” ANS: D Blurred and cloudy vision should be immediately reported because it is likely that the client is developing cataracts and the tamoxifen will be discontinued or decreased. Tamoxifen treatment generally lasts 5 years. Hot flashes are an expected adverse effect of tamoxifen. Leg cramps may be a sign of deep vein thrombosis, and the client should immediately notify the health care provider if pain occurs. DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation 19. Which of the following actions should the nurse take first when caring for a client who has been admitted for lumpectomy and axillary lymph node dissection? a. Teach the client how to deep breathe and cough. b. Discuss options for postoperative pain management. c. Explain the postdischarge care of the axillary drains. d. Ask the client to describe what she knows about the surgery. ANS: D Before teaching, the nurse should assess the client’s current knowledge level. The other teaching also may be appropriate, depending on the assessment findings. NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 20. When the nurse is working in the women’s health care clinic, which of the following actions is appropriate to take? a. Educate a healthy 36-year-old about the need for an annual mammogram. b. Discuss the need for an annual mammography with a 52-year-old. c. Talk about magnetic resonance imaging (MRI) with a 26-year-old with a BRCA-1 mutation. d. Teach an active 70-year-old that mammography frequency should be individualized based upon her history. ANS: C MRI (in addition to mammography) is recommended for women who are at high risk for breast cancer. A 52-year-old client should have a mammography every 2 years. Mammography screening is recommended for women starting at age 40 if they are considered high-risk for the development of breast cancer. For healthy older women, an individualized plan of care should be discussed with her health care provider. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 21. The nurse is caring for a client with left arm lymphedema. Which of the following actions should be included in the plan of care? a. Check BP on both right and left arms. b. Avoid isometric exercise on the left arm. c. Assist with application of compression dressings. d. Keep the left arm at or below the level of the heart. ANS: C Compression of the arm assists in improving lymphatic flow toward the heart. Isometric exercises may be prescribed for lymphedema. BPs should only be done on the client’s right arm. The arm should not be placed in a dependent position. DIF: Cognitive Level: Application TOP: Nursing Process: Planning 22. A client who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic with these symptoms. Which of the following findings is most important to report to the health care provider? a. There is yellow-green discharge from one of the client’s nipples. b. There is an area on the breast that is hot, red, and tender to touch. c. The lumps are firm feeling and most are in the upper outer breast quadrants. d. The lumps are larger and more painful before the client’s menstrual period. ANS: B An area that is hot or red suggests an infectious process such as mastitis, which would require further assessment and treatment. The other information will also be reported, but these findings are typical in fibrocystic breasts. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 23. The nurse is assessing a male client and notes bilateral enlargement of the breasts. Which of the following actions should the nurse take first? NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank NURSINGTB.COM a. Question the client about any medications being currently used. b. Teach the client about how to palpate the breast tissue for lumps. c. Refer the client for mammography and biopsy of the breast tissue. d. Explain that this is a temporary condition due to hormonal changes. ANS: A The first action should be further assessment. Since gynecomastia is a possible adverse effect of drug therapy, asking about the current drug regimen is appropriate. The other actions may be needed, depending on the data that are obtained with further assessment. DIF: Cognitive Level: Application TOP: Nursing Process: Implementation 24. The nurse is caring for a client with breast cancer who is receiving chemotherapy and tamoxifen. Which of the following findings is most important to communicate to the health care provider? a. The client has symptoms of numbness and tingling in the right arm and leg. b. The client has complaints of fatigue. c. The client eats only 15% of food on meal tray. d. The client’s white blood cell (WBC) count is 5 u 109/L. ANS: A One-sided tingling and numbness may indicate a stroke and should be reported to the health care provider. Tamoxifen increases the risk of blood clots, cataracts, stroke, and endometrial cancer in postmenopausal women. Anorexia, fatigue, and a low-normal WBC count are expected effects of chemotherapy. DIF: Cognitive Level: Application TOP: Nursing Process: Assessment 25. The nurse is assessing a client with Paget’s disease. Which of the following findings should the nurse anticipate that the client may experience? a. Greenish coloured nipple discharge b. Itchiness of the breast c. Increased temperature d. Nipple inversion ANS: B A client with Paget’s disease may experience itching, burning sensation, bloody nipple discharge with superficial erosion, and ulceration may be present. A client with Paget’s disease generally does not have a temperature. The discharge is bloody from the nipple, not a greenish colour. DIF: Cognitive Level: Application TOP: Nursing Process: Planning NURSINGTB.COM Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank