Lewis Chapter 51

To prevent capsular formation after breast reconstruction with implants, teach the patient to a. gently massage the area around the implant. b. bind the breasts tightly with elastic bandages. c. avoid strenuous exercise until the implant has healed. d. exercise the arm on the affected side to promote drainage.

a Although providers have different approaches to the prevention of contracture formation, gentle manual massage around the implant is a routine practice.

A 50-yr-old patient is preparing to begin breast cancer treatment with tamoxifen. What point should the nurse emphasize when teaching the patient about her new drug regimen? a. "Report any changes in your vision immediately." b. "The medication may cause some breast sensitivity." c. "The drug often alleviates some menopausal symptoms." d. "Abstain from drinking alcohol after you begin taking tamoxifen."

a Tamoxifen has the potential to cause cataracts and retinopathy. The drug is likely to exacerbate rather than alleviate perimenopausal symptoms. Breast tenderness is not associated with tamoxifen. It is not necessary to abstain from alcohol.

When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is a. being a woman over age 60. b. experiencing menstruation for 30 years or more. c. using hormone therapy for 5 years for menopausal symptoms. d. having a paternal grandmother with postmenopausal breast cancer.

a The identifiable risk factors most associated with breast cancer include female gender and advancing age. The incidence of breast cancer is very low in women younger than 25 years and increases gradually with age until 60 years. After age 60, the incidence increases dramatically.

A 72-yr-old patient had a mastectomy for breast cancer 6 months ago and wants to have breast reconstructive surgery. Which motivation for surgery would be most likely? a. Improve the woman's self-image. b. Be able to experience sexual arousal. c. To get a tummy tuck as well as the breast mound. d. Restore the premastectomy appearance of the breast.

a The most likely motivation for this patient to seek breast reconstructive surgery is to improve her self-esteem. With this surgery, she will not be able to experience sexual arousal through breast stimulation or restore the premastectomy appearance of the breast. The abdominoplasty (tummy tuck) effect will only be a possibility with the transverse rectus abdominis musculocutaneous (TRAM) flap, not with a breast implant or tissue expansion

A patient with breast cancer has a lumpectomy with sentinel lymph node biopsy that is positive for cancer. You explain that, of the other tests done to determine the risk for cancer recurrence or spread, the results that support the more favorable prognosis are (select all that apply) a. well-differentiated tumor. b. estrogen receptor-positive tumor. c. overexpression of HER-2 cell marker. d. involvement of two to four axillary nodes. e. aneuploidy status from cell proliferation studies.

a, b In general, the more well differentiated the tumor is, the less aggressive it is. Poorly differentiated tumors appear morphologically disorganized and are more aggressive. Another diagnostic test useful for treatment decisions and prognosis is determination of estrogen and progesterone receptor status. Receptor-positive tumors (1) often show histologic evidence of being well differentiated, (2) often have a diploid (more normal) DNA content and low proliferative indices, (3) have a lower chance for recurrence, and (4) are often hormone dependent and responsive to hormone therapy.

A patient presents with mastalgia. After determining cancer is not present, which strategies may provide relief? (Select all that apply.) a. Application of ice b. Oral contraceptives c. Reduce caffeine intake d. Increase intake of fluids e. Oral antibiotic administration f. Wear a supportive bra during the day

a, b, c, f To reduce breast pain, the patient may apply ice, reduce caffeine intake, and use oral contraceptive therapy. Wearing a supportive bra continuously may reduce discomfort. Increasing fluids and use of antibiotics are not indicated for treatment of mastalgia.

The nurse is volunteering at a community center to teach women about breast cancer. What should the nurse include when discussing risk factors? (Select all that apply.) a. Nulliparity b. Alcohol use c. Age 30 or over d. Early menarche e. Late menopause f. Personal history of colon cancer

a, b, d, e, f Women are at an increased risk for development of breast cancer if they are older than the age of 50 years; have a family history of breast cancer; have a personal history of breast, colon, endometrial, or ovarian cancer; have a long menstrual history as seen with early menarche or late menopause; and have had a first full-term pregnancy after the age of 30 years or are nulliparous. Alcohol use may increase the risk of breast cancer.

You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. Which recommendations you would include? (select all that apply) a. Women over age 55 may have biennial screening. b. Screening should end when the women reaches age 65. c. Women aged 45 to 54 years should be screened annually. d. Regular screening mammography should start at age 45 years. e. Clinical breast examinations can be used if the woman has average risk.

a, c, d For women at average risk for breast cancer, the American Cancer Society (ACS) recommended guidelines include: • Women should undergo regular screening mammography starting at age 45 years. • Women aged 45 to 54 years should be screened annually. • Women 55 years and older should transition to biennial screening or be able to continue screening annually. • Women should continue screening if their overall health is good, and they have a life expectancy of 10 years or longer. • The ACS does not recommend depending on clinical breast examination for breast cancer screening among average-risk women at any age.

A 24-yr-old patient had breast augmentation surgery and will be discharged the same day. What instructions should the nurse provide to minimize the risk of complications in the immediate recovery period? a. Avoid wearing a bra until postoperative day 3. b. Avoid strenuous exercise during her recovery period. c. Sleep in a semi-Fowler's position until her scheduled follow-up appointment. d. Enlist a friend or family member to perform passive range-of-motion exercises.

b As with all types of breast surgery, strenuous exercise is contraindicated during the recovery period after breast augmentation. A bra should be worn to prevent dehiscence and provide comfort. Sleeping in a semi-Fowler's position is not necessary, and passive range-of-motion exercises should be avoided at first.

Which task could the registered nurse delegate to unlicensed assistive personnel (UAP) during the care of a patient who has had recent transverse rectus abdominis musculocutaneous (TRAM) flap surgery? a. Document the condition of the patient's incisions. b. Mobilize the patient in a slightly hunched position. c. Change the patient's abdominal and chest dressings. d. Change the parameters of the patient-controlled analgesic (PCA) pump.

b Mobilization of a postsurgical patient may be delegated, and a patient who has had a TRAM flap should not stand or walk fully erect in order to minimize strain on the incisions. Changing dressings, assessing wounds, and reprogramming a PCA pump are not appropriate tasks to delegate to UAP.

The nurse is caring for a patient diagnosed with breast cancer who just underwent an axillary lymph node dissection. What intervention should the nurse use to decrease the lymphedema? a. Keep affected arm flat at the patient's side. b. Apply an elastic bandage on the affected arm. c. Assess blood pressure only on unaffected arm. d. Restrict exercise of the affected arm for 1 week.

c Blood pressure readings, venipunctures, and injections should not be done on the affected arm. Elastic bandages should not be used in the early postoperative period because they inhibit collateral lymph drainage. The affected arm should be elevated above the heart, and isometric exercises are recommended and gradually increased starting in the recovery room to reduce fluid volume in the arm.

The nurse is caring for a patient with breast cancer who is receiving high-dose doxorubicin (Adriamycin). Which assessment is most important for the nurse to make? a. Observe for alopecia. b. Determine visual acuity. c. Monitor cardiac rhythm. d. Assess mouth and throat.

c Doxorubicin (especially at high doses) may cause cardiotoxicity and heart failure. The nurse should monitor for dysrhythmias, electrocardiogram changes, and manifestations of heart failure. Other adverse effects of doxorubicin include stomatitis and alopecia, but these effects are not as serious as cardiac problems. Tamoxifen may cause visual changes.

A 29-yr-old primiparous patient is breastfeeding a 3-wk-old infant. She reports recent breast tenderness, redness, and fever. Which teaching point should the nurse reinforce when following up on her care? a. Refer the patient for a mammogram as quickly as possible. b. Encourage the patient to continue breastfeeding her infant. c. Ensure patient adheres to her prescribed antibiotic regimen. d. Teach the patient to use warm compresses and the self-limiting nature of illness.

c Mastitis normally requires antibiotic therapy that is closely adhered to. Breastfeeding should be continued if possible, but effective treatment of infection would be the immediate priority. If a palpable mass develops, medical follow-up may be needed to determine if an abscess is present. Mastitis is not necessarily self-limiting, and mammography is not normally indicated.

The nurse caring for patients in a primary care clinic identifies which patient as at highest risk for developing breast cancer? a. A 59-yr-old who has inherited the APC gene b. A 25-yr-old with fibrocystic breast disease c. A 72-yr-old with a family history of breast cancer d. A 43-yr-old who is obese and leads a sedentary lifestyle

c The risk factors most associated with breast cancer are female gender, advancing age, and family history. The incidence of breast cancer increases dramatically after age 60 years. Mutations in BRCA genes may cause 5% to 10% of breast cancers; The APC gene is associated with colon cancer. Obesity and physical inactivity increase the risk for breast cancer. Fibrocystic breast disease is not associated with the development of breast cancer.

Preoperatively, to meet the psychologic needs of a woman scheduled for a simple mastectomy, you would a. discuss the limitations of breast reconstruction. b. include her significant other in all conversations. c. promote an environment for expression of feelings. d. explain the importance of regular follow-up screening.

c Throughout interactions with a patient with breast cancer, you should be aware of the extensive psychologic impact of the disease. Effective care includes sensitivity to the patient's efforts to cope with a life-threatening disease. You should provide a safe environment for the expression of the full range of feelings.

When doing breast self-examination, the female patient should report which finding to the health care provider? a. Denser breast tissue b. Palpable rib margins c. Left nipple deviation d. Different sized breasts

c Unilateral deviation of a nipple may be a clinical indicator of breast cancer or other problem and should be reported to the health care provider. Dense breast tissue, palpable rib margins, and different sized breasts are all normal findings.

A nurse is teaching a health promotion workshop to a group of women in their 40s and 50s. What information about nipple discharge should the nurse teach to participants? a. Inappropriate lactation necessitates breast biopsy. b. Nipple discharge of any type is a precursor to cancer. c. Galactorrhea is a normal symptom related to perimenopause. d. Unexpected nipple discharge of any type needs medical follow-up.

d Although most cases of nipple discharge are not related to malignancy, further medical assessment is indicated. Other testing would be done for inappropriate lactation before a breast biopsy would be necessary. Galactorrhea is not considered a normal age-related change, nor is it a common perimenopausal symptom.

The patient with breast cancer has a left mastectomy with axillary node dissection. Ten lymph nodes are resected with 3 positive for cancer cells. The patient has stage IIB breast cancer. Which nursing intervention would be most effective in planning care? a. Evaluate left arm lymphatic accumulation. b. Maintain joint flexibility and left arm function. c. Teach her about chemotherapy and radiation therapy. d. Assess the patient's response to the diagnosis of breast cancer.

d Assessment is the first step in planning patient care. Because the nurse is the patient's advocate and this is an extremely stressful time for the patient and family, the nurse should focus on the patient's response to the diagnosis of breast cancer when planning care. The approach for the care of the left arm and teaching the patient about further therapy will be based on the initial assessment.

The nurse is caring for an obese woman after a right mastectomy with axillary lymph node dissection. Which discharge instruction should the nurse include? a. "Arm exercises should not be started for 4 to 6 weeks." b. "Discontinue arm exercises if you have discomfort or pain." c. "Special massage therapy can decrease swelling in your arm." d. "Keep your right arm in a sling to decrease pain and swelling."

d Decongestive therapy may be used for acute lymphedema and includes a massage-like technique to mobilize the subcutaneous accumulation of fluid. Arm exercises should be performed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation. The arm exercises should be initiated after surgery and increased gradually. Pain medications should be administered 30 minutes before arm exercises. The operative arm should be kept at the level of the heart but not in a sling; a sling discourages use of the arm.

The nurse performs a breast examination on a 68-yr-old female patient. Which finding indicates further evaluation for breast cancer is needed? a. Bilateral pendulous breasts b. Right breast is warm, painful to touch c. Palpable lump that is tender and movable d. Irregular, nontender lump with induration

d Manifestations of breast cancer may include a palpable lump that is hard, irregular, poorly delineated, nonmobile, and nontender. Nipple retraction, peau d'orange, induration, and dimpling of the overlying skin may also be noted. Mastitis presents with breasts that are warm to touch, indurated, and painful. Atrophy of the mammary glands associated with aging may result in pendulous breasts. Manifestations of fibrocystic breast changes include palpable lumps that are round, well delineated, and freely movable. The lump is usually tender and increases in size and tenderness before menstruation.

A patient recently had a unilateral, right total mastectomy and axillary node dissection for the treatment of breast cancer. What nursing intervention should the nurse include in the patient's care? a. Immobilize the patient's right arm until postoperative day 3. b. Maintain the patient's right arm in a dependent position when at rest. c. Administer diuretics prophylactically for the prevention of lymphedema. d. Promote gradually increasing mobility as soon as possible following surgery.

d Mobility should be encouraged beginning in the postanesthesia care unit (PACU) and increased gradually throughout the patient's recovery. Immobilization is counterproductive to recovery, and the limb should not be in a dependent position. Diuretics are not used to prevent lymphedema but may be used in active treatment of the problem.

You are caring for a patient with breast cancer following a simple mastectomy. Postoperatively, to restore arm function on the affected side, you would a. apply heating pads or blankets to increase circulation. b. place daily ice packs to minimize the risk for lymphedema. c. teach passive exercises with the affected arm in a dependent position. d. emphasize regular exercises for the affected shoulder to increase range of motion.

d Restoring arm function on the affected side after mastectomy and axillary lymph node sampling is a key nursing goal. Place the woman in a semi-Fowler's position with the arm on the affected side elevated on a pillow. Flexing and extending the fingers should begin in the recovery room, and progressive increases in activity should be encouraged. Postoperative arm and shoulder exercises are started gradually under a HCP's direction. These exercises are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation. The goal of all exercise is a gradual return to full range of motion within 4 to 6 weeks.

The nurse teaches a 53-yr-old patient about screening for early detection of breast cancer. Which statement requires clarification by the nurse? a. "I should plan to have a mammogram every year." b. "A breast examination should be done right after my menstrual period." c. "I will see the health care provider every year for a breast examination." d. "Self-breast examination is a reliable way to detect breast cancer early."

d Screening for the early detection of breast cancer includes yearly mammograms starting at age 45 years. Breast self-examination (BSE) has benefits and limitations and may not be a reliable method for early detection of breast cancer. BSE is optional, but it should be done in premenopausal women right after the menstrual period when the breasts are less lumpy and tender.

You are caring for a young woman who has painful fibrocystic breast changes. Management of this patient would include a. scheduling a biopsy to rule out the presence of breast cancer. b. teaching that symptoms will subside if she stops using oral contraceptives. c. preparing her for surgical removal of the lumps, since they will become larger and more painful. d. explaining that restricting coffee and chocolate and supplementing with vitamin E may relieve some discomfort.

d Some relief for cyclic breast pain may be obtained with reducing caffeine and dietary fat; taking vitamin E, gamma-linolenic acid (i.e., evening primrose oil); and wearing a supportive bra. Compresses, ice, analgesics, and antiinflammatory drugs may help. Drugs may be recommended, including tamoxifen and danazol (Danocrine)