BREAST CANCER

1. You are a community health nurse planning a program on breast cancer screening guidelines for women in the neighborhood. To best promote the participants' learning and adherence, you would include (select all that apply) a. a short audiotape on the BSE procedure. b. a packet of articles from the medical literature. c. written guidelines for mammography and CBE. d. a discussion of the value of early breast cancer detection. e. community resources where they can obtain an ultrasound and MRI.

1. Correct answers: c, d Rationale: When teaching women about breast cancer screening guidelines, include information related to potential benefits, limitations, and harm (e.g., chance of a false-positive result). Allow time for questions about the procedure and a return demonstration. At every periodic health examination, ask the woman who is performing breast self-examination (BSE) to demonstrate her technique. Demonstration of BSE and providing written guidelines are appropriate teaching methods.

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

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

8. To prevent capsular formation a er 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. exercise the arm on the a ected side to promote drainage. d. avoid strenuous exercise until the implant has healed.

8. Correct answer: a Rationale: Surgeons have different approaches to the prevention of contracture formation, although gentle manual massage around the implant is routine.

8. Which characteristics describe an intraductal papilloma (select all that apply)? a. Associated with breast trauma b. Occurs in 10% of women ages 15 to 40 c. Has multicolored, sticky nipple discharge d. Is associated with an increased cancer risk e. Is more common in women ages 40 to 60 f. Has wartlike growth in mammary ducts near nipple

8. d, e, f. Intraductal papilloma is associated with increased cancer risk, is more common in women 40 to 60 years old, and is a wartlike growth in mammary ducts beneath the areola. Fat necrosis is associated with breast trauma. Fibroadenoma occurs in 10% of young women. Multicolored, sticky nipple discharge is seen in ductal ectasia.

13. A 72-year-old patient who had a mastectomy for breast cancer 6 months ago wants to have breast reconstructive surgery. The nurse knows that what is the most likely motivation for this patient seeking this surgery? Improve the woman's self-image Be able to experience sexual arousal To get a tummy tuck as well as the breast mound Restore the pre-mastectomy 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 or restore the pre-mastectomy 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.

2. 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 Age 30 or over C Early menarche D Late menopause E Personal history of colon cancer

A C D E Women are at an increased risk for development of breast cancer if they are over the age of 50; 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 or are nulliparous.

3. The nurse has been asked to participate in a healthy living workshop. While teaching about women's health, which guidelines should the nurse provide to the audience? A "Mammograms are necessary if you have a family history of breast cancer." B "It's recommended that you get a mammogram each year after you turn 40." C "If you are not able to perform breast self-examination (BSE), you should go for regular mammograms." D "You should ensure that your primary care provider performs a breast exam each time you visit."

B Annual mammograms are recommended after age 40. They are recommended for all women, not solely those with a family history of breast cancer. BSE is not a replacement for mammography, and clinical breast examinations are not necessary at each office visit, but recommended at least every 3 years for women in their 20s and 30s, and then every year beginning at age 40.

9. A 24-year-old patient who has undergone breast augmentation earlier in the day will be discharged home in the early evening. What instructions should the nurse provide in order to minimize the patient's risk of complications in the immediate recovery period? A Avoid wearing a bra until postoperative day 3. B Ask the patient to 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 following 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.

6. 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 the 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.

11. When caring for female patients, the nurse should be aware that most cancers occur where on the breast? A lower outer quadrant B upper outer quadrant C upper inner quadrant D nipple area

B Most (50%) breast cancers are diagnosed in the upper outer quadrant of the breast. The next most frequent site is the nipple area (18%), followed by the upper medial area (15%), the lower outer quadrant (11%), and the lower medial area (6%).

10. When doing breast self-examination, the female patient should report which findings to her physician? A Palpable rib margins B Denser breast tissue 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.

1. A woman at the health clinic tells the nurse that she does not do breast self-examination (BSE) because it just seems too much of a bother. What is the best response by the nurse about BSE? a. It reduces mortality from breast cancer in women under the age of 50. b. It is useful to help women learn how their breasts normally look and feel. c. BSE has little value in detection of cancer and is not recommended anymore. d. BSE is the most common way that malignant tumors of the breast are discovered.

1. b. The value of breast self-examination (BSE) in reducing mortality rates from breast cancer in women is currently controversial and under review. However, it is still a useful tool in helping women to become self-aware of how their breasts normally look and feel. None of the other options has been validated at this time.

10. Which patient probably has the highest risk of breast cancer? a. 60-year-old obese man b. 58-year-old woman with sedentary lifestyle c. 55-year-old woman with fibrocystic breast changes d. 65-year-old woman with a sister diagnosed with breast cancer

10. d. After the age of 60, the incidence of breast cancer increases dramatically and advanced age is the highest risk factor for females. Ninety-nine percent of breast cancer cases occur in women. A first-degree relative with breast cancer is a contributing factor for breast cancer. Obesity and lack of physical activity are other contributing factors. Genetic mutations in BRCA1, BRCA2, p53, ATM, and CHEK2 genes may increase the risk of breast cancer. Fibrocystic breast changes are neither a precursor of breast cancer nor a known risk factor for cancer.

11. The nurse would be most concerned when the patient's breast examination reveals which finding? a. A large, tender, moveable mass in the upper inner quadrant b. An immobile, hard, nontender lesion in the upper outer quadrant c. A 2- to 3-cm, firm, defined, mobile mass in the lower outer quadrant d. A painful, immobile mass with reddened skin in the upper outer quadrant

11. b. On palpation, malignant lesions are characteristically hard, irregularly shaped, poorly delineated, nontender, and nonmobile and the most common site is the upper outer quadrant of the breast. A fibroadenoma is firm, defined, and mobile. Fibrocystic lesions are usually large, tender, moveable masses found throughout the breast tissue. A painful, immobile mass under a reddened area of skin is most typical of a local abscess.

12. The best prognosis is indicated in the patient with breast cancer when diagnostic studies reveal a. negative axillary lymph nodes. b. aneuploid DNA tumor content. c. cells with high S-phase fractions. d. an estrogen receptor- and progesterone receptor-negative tumor.

12. a. Axillary lymph node status is one of the most important prognostic factors in primary breast cancer; the more nodes involved, the higher the risk for relapse or metastasis. Aneuploid DNA tumor content indicates that cells have abnormally high or low DNA content compared with normal cells and is associated with tumor aggressiveness. Cells in S-phase have a higher risk for recurrence and can produce earlier cancer death. Hormone receptor-negative tumors are usually poorly differentiated histologically, frequently recur, and are usually unresponsive to hormonal therapy.

13. The health care provider of a patient with a positive biopsy of a 2-cm breast tumor has recommended a lumpectomy with radiation therapy or a modified radical mastectomy as treatment. The patient says that she does not know how to choose and asks the female nurse what she would do if she had to make the choice. What is the best response by the nurse to this patient? a. "It doesn't matter what I would do. It is a decision you have to make for yourself." b. "There are advantages and disadvantages of both procedures. What do you know about these procedures?" c. "I would choose the modified radical mastectomy because it would ensure that the entire tumor was removed." d. "The lumpectomy maintains a nearly normal breast but the survival rate is not as good as it is with a mastectomy."

13. b. Either treatment choice is indicated for women with early-stage breast cancer because the 10-year survival rate with lumpectomy with radiation is about the same as that with modified radical mastectomy. Each procedure has advantages and disadvantages that the patient must consider in making an informed choice and the nurse should make that information available to the patient to assist in decision making.

14. A patient undergoing either a mastectomy or a lumpectomy for treatment of breast cancer can also usually expect to undergo what other treatment? a. Chemotherapy b. Radiation therapy c. Hormonal therapy d. Sentinel lymph node dissection

14. d. Sentinel lymph node dissection (SLND) has become the standard of care, with axillary lymph node dissection reserved for patients with clinical indications of disease in the axilla. SLND provides prognostic information and helps to determine further treatment. A lumpectomy, or breast- conservation surgery, is followed by radiation therapy to he entire breast and the use of chemotherapy or hormone therapy depends on the characteristics of the tumor and evidence of metastases.

15. Lymphatic mapping with sentinel lymph node dissection (SLND) is planned for a patient undergoing a modified radical mastectomy for breast cancer. What does the nurse teach the patient and her family? a. If one sentinel lymph node is positive for malignant cells, all of the sentinel lymph nodes will be removed. b. If malignant cells are found in any sentinel nodes, a complete axillary lymph node dissection will be done. c. Lymphatic mapping indicates which lymph nodes are most likely to have metastasis and all of those nodes are removed. d. Lymphatic mapping with SLND provides metastatic lymph nodes to test for responsiveness to chemotherapy.

15. c. Lymphatic mapping with SLND identifies one to four lymph nodes that drain first from the tumor site. Those nodes are examined for malignant cells. If any of the nodes have malignant cells, a complete axillary lymph node dissection is done. If the sentinel nodes are negative, no additional lymph nodes are removed.

16. What describes the use of high-dose brachytherapy radiation (select all that apply)? a. May be completed in 5 days b. Follows local excision of tumor c. Alternative to traditional radiation therapy for early-stage breast cancer d. Used to treat possible local residual cancer cells following a mastectomy e. Used to reduce tumor size and stabilize metastatic lesions for pain relief

16. a, c. High-dose brachytherapy may be completed in 5 days and is an alternative to traditional radiation for early-stage breast cancer. Primary radiation follows local excision of a tumor. Radiation as an adjuvant to surgery is used to treat possible residual cancer cells postmastectomy. Palliative radiation is used to reduce tumor size and relieve pain.

17. A patient with a positive breast biopsy tells the nurse that she read about tamoxifen (Nolvadex) on the Internet and asks about its use. The best response by the nurse includes which information? a. Tamoxifen is the primary treatment for breast cancer if axillary lymph nodes are positive for cancer. b. Tamoxifen is used only to prevent the development of new primary tumors in women with high risk for breast cancer. c. Tamoxifen is the treatment of choice after surgery if the tumor has receptors for estrogen and progesterone on its cells. d. Because tamoxifen has been shown to increase the risk for uterine cancer, it is used only when other treatment has not been successful.

17. c. Tamoxifen is an antiestrogen agent that blocks the estrogen-receptor sites of malignant cells and is the usual first choice of treatment in postmenopausal women with hormone receptor-positive tumors, with or without nodal involvement. Tamoxifen reduces the risk for recurrent breast cancer and also that for new primary tumors. The side effects of the drug are minimal and are those commonly associated with decreased estrogen.

18. During the immediate postoperative period following a mastectomy, the nurse initially institutes which exercises for the affected arm? a. Have the patient brush or comb her hair with the affected arm. b. Perform full passive range-of-motion (ROM) exercises to the affected arm. c. Ask the patient to flex and extend the fingers and wrist of the operative side. d. Have the patient crawl her fingers up the wall, raising her arm above her head.

18. c. As early as in the recovery room following a modified radical mastectomy, the patient should start flexing and extending the fingers and wrist of the affected arm with daily increases in activity. Postoperative mastectomy exercises, such as hair care, wall climbing with the fingers, and shoulder rotation and extension, are instituted gradually to prevent disruption of the wound.

19. Following a modified radical mastectomy, a patient develops lymphedema of the affected arm. What does the nurse teach the patient to do? a. Avoid skin-softening agents on the arm. b. Protect the arm from any type of trauma. c. Abduct and adduct the arm at the shoulder hourly. d. Keep the arm positioned so that it is in straight and dependent alignment.

19. b. Removal of the axillary lymph nodes impairs lymph drainage from the affected arm and predisposes the patient to infection of the arm. The arm must be protected from even minor trauma and blood pressure, venipunctures, and injections should not be done on the arm. The arm should never be dependent, even during sleep, and should be elevated to promote lymph drainage.

2. In teaching a patient who wants to perform BSE, you inform her that the technique involves both the palpation of the breast tissue and a. palpation of cervical lymph nodes. b. hard squeezing of the breast tissue. c. a mammogram to evaluate breast tissue. d. inspection of the breasts for any changes.

2. Correct answer: d Rationale: BSE is performed by palpation of breast tissue with three levels of pressure. The breasts should be inspected for size, shape, redness, scaliness, or dimpling of the breast skin or nipple.

20. A patient undergoing surgery and radiation for treatment of breast cancer has a nursing diagnosis of disturbed body image related to absence of the breast. What is an appropriate nursing intervention for this patient? a. Provide the patient with information about surgical breast reconstruction. b. Restrict visitors and phone calls until the patient feels better about herself. c. Arrange for a Reach to Recovery visitor or similar resource available in the community. d. Encourage the patient to obtain a permanent breast prosthesis as soon as she is discharged from the hospital.

20. c. The Reach to Recovery program consists of volunteers, all women, who have had breast cancer and can answer questions about what to expect at home, how to tell people about the surgery, and what prosthetic devices are available. It is a valuable resource for patients who have breast cancer and should be used if available in the community. If a volunteer is not available, the nurse is responsible for assisting the patient in the same manner. Although the nurse should stress the importance of wearing a prosthesis, a permanent prosthesis cannot be used until healing is complete and inflammation is resolved.

21. A 56-year-old patient is undergoing a mammoplasty for breast reconstruction following a mastectomy 1 year ago. During the preoperative preparation of the patient, what is important for the nurse to do? a. Determine why the patient is choosing reconstruction surgery rather than the use of an external prosthesis. b. Ensure that the patient has realistic expectations about the outcome and possible complications of the surgery. c. Inform the patient that implants used for breast reconstruction have been shown to cause immune-related diseases. d. Let the patient know that although the shape will be different from the other breast, the nipple can be reconstructed from other erectile tissue.

21. b. It is most important for the patient planning a mammoplasty that she have a realistic idea about what the surgery can accomplish and about possible complications. Currently surgery cannot restore nipple sensation or erectility and the breast will not fully resemble its premastectomy appearance but the outcome is usually more acceptable than the mastectomy scar. The woman's motives for breast reconstruction should not be questioned. There have been allegations of immune-related diseases associated with the use of silicone gel implants but after further evaluation the Food and Drug Administration (FDA) has approved these implants for use.

22. A patient undergoing a modified radical mastectomy for cancer of the breast is going to use tissue expansion and an implant for breast reconstruction. What should the nurse teach the patient about tissue expansion? a. Weekly injections of water or saline into the expander will be required. b. The expander cannot be placed until healing from the mastectomy is complete. c. This method of breast reconstruction uses the patient's own tissue to replace breast tissue. d. The nipple from the affected breast will be saved to be grafted onto the reconstructed breast.

22. a. When an expander is used to stretch the skin and muscle at the mastectomy site, the expander is gradually increased n size by weekly injections of water or saline until the site is large enough to hold an implant. Placement of the expander can be at the time of mastectomy or at a later date. A musculocutaneous flap procedure is a type of reconstruction using the patient's own tissue. The nipple of the affected breast is removed at mastectomy and a new nipple can be reconstructed after breast reconstruction from various normal tissues.

23. The patient's breast cancer has metastasized. Which medication for metastasis is better tolerated and has fewer and milder side effects than other chemotherapy medications? a. Capecitabine (Xeloda) b. Vinorelbine (Navelbine) c. Doxorubicin (Adriamycin) d. Eribulin mesylate (Halaven)

23. b. Vinorelbine (Navelbine) is used to treat metastatic breast cancer and is better tolerated with fewer and milder side effects than other chemotherapy medications. Capecitabine (Xeloda) is used in women whose metastatic breast cancer has not responded to started chemotherapy. Doxorubicin (Adriamycin) is a first-line chemotherapy medication and has severe side effects, especially cardiotoxicity. Eribulin mesylate (Halaven) is used in metastatic breast cancer patients who have received at least two prior chemotherapy regimens.

3. You are caring for a young woman who has painful brocystic breast changes. Management of this patient would include a. scheduling a biopsy to rule out malignant changes. b. teaching that symptoms will probably 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 restrictions of co ee and chocolate and supple- ments of vitamin E may relieve some discomfort.

3. Correct answer: d Rationale: Some relief for cyclic breast pain may be obtained with reductions in caffeine and dietary fat; taking vitamins E, A, and B-complex and gamma-linolenic acid (i.e., evening primrose oil); and continually wearing a support bra. Compresses, ice, analgesics, and antiinflammatory drugs may help. Drugs may be recommended, including oral contraceptives and danazol (Danocrine).

3. When teaching a 24-year-old woman who desires to learn BSE, the nurse knows that it is important to do what? a. Provide time for a return demonstration. b. Emphasize the statistics related to breast cancer survival and mortality. c. Have the woman set a consistent monthly date for performing the examination. d. Inform the woman that professional examinations are not necessary unless she finds an abnormality.

3. a. One of the major reasons why women do not examine their breasts regularly is because of a lack of confidence in BSE skill. A teaching program should include allowing time for women to use models to identify problems and perform a return demonstration of the examination on themselves. Fear and denial often interfere with BSE even when women know that the perceived risk for cancer is high, know the statistics, and know that they should seek medical care if an abnormality is detected. Examinations in premenopausal women should be done right after the menstrual period and specific dates are set for postmenopausal women or those who have had hysterectomies.

4. 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.

4. Correct answer: a Rationale: 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.

4. Which diagnostic test is most accurate and advantageous in terms of time and expense in diagnosing malignant breast disorders? a. Surgical biopsy b. Mammography c. Fine-needle aspiration d. Core (core needle) biopsy

4. d. A definitive diagnosis of breast cancer can be made only by a histologic examination of biopsied tissue. A core (core needle) biopsy is as reliable as a surgical biopsy and has the advantages of decreased length of time for the procedure and recovery and reduced cost. A limitation of fine-needle aspiration is that if negative results are found, more definitive biopsy procedures are required.

5. A patient with breast cancer has a lumpectomy with sentinel lymph node dissection 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-di erentiated 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.

5. Correct answers: a, b Rationale: 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) commonly show histologic evidence of being well differentiated, (2) frequently have a diploid (more normal) DNA content and low proliferative indices, (3) have a lower chance for recurrence, and (4) are frequently hormone dependent and responsive to hormonal therapy.

5. A 24-year-old female patient has breast cancer with estrogen receptor-negative cells. Which genomic assay test can be used to provide information about the likely recurrence and need for chemotherapy? a. CA 27-29 b. TNM system c. Oncotype DX d. MammaPrint

5. d. MammaPrint is used in early-stage breast cancer with estrogen receptor-positive or estrogen receptor-negative breast cancer without nodal involvement to assess risk of recurrence within 10 years without additional treatment and the likely benefit of chemotherapy. CA 27-29 is a cancer marker produced by the MUC1 gene. TNM is not a genomic assay but rather a system for staging cancer using tumor size, nodal involvement, and the presence of metastasis. Oncotype DX genomic assay is used in newly diagnosed early-stage estrogen receptor-positive breast cancer treated with hormonal therapy to assess risk of occurrence and the need for treatment with chemotherapy to prevent recurrence.

6. A modified radical mastectomy has been scheduled for your patient with breast cancer. Postoperatively, to restore arm function on the a ected side, you would a. apply heating pads or blankets to increase circulation. b. place daily ice packs to minimize the risk of lymphedema. c. teach passive exercises with the a ected arm in a dependent position. d. emphasize regular exercises for the a ected shoulder to increase range of motion.

6. Correct answer: d Rationale: Restoring arm function on the affected side after mastectomy and axillary lymph node dissection 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 instituted gradually under a surgeon'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.

6. While examining a patient's breasts, the nurse notes multiple, bilateral mobile lumps. To assess the patient further, what is the most appropriate question by the nurse? a. "Do you have a high caffeine intake?" b. "When did you last have a mammogram?" c. "Is there a history of breast cancer in your mother or sisters?" d. "Do the size and tenderness of the lumps change with your menstrual cycle?"

6. d. Most breast lesions are benign and many mobile cystic lesions change in response to the menstrual cycle, whereas most malignant tumors do not. Caffeine has been associated with fibrocystic changes in some women but research has not established caffeine as a cause of breast pain or cysts. Questions regarding a patient's last mammogram or family history are not closely related to the nurse's findings.

7. A patient has fibrocystic changes in her breast. The nurse explains to the patient that this condition is significant because it a. commonly becomes malignant over time. b. can be controlled with hormone therapy (HT). c. makes it more difficult to examine the breasts. d. will eventually cause atrophy of normal breast tissue.

7. c. Fibrocystic changes make breasts difficult to examine because of fibrotic changes and multiple lumps. A woman with this condition should be familiar with the characteristic changes in her breasts and monitor them closely for new lumps that do not respond in a cyclic manner over 1 to 2 weeks. Estrogen antagonizes the condition and fibrocystic changes are not precancerous.

9. Which benign breast disorder occurs most often during lactation and is commonly caused by Staphylococcus aureus? a. Mastitis b. Ductal ectasia c. Fibroadenoma d. Senescent gynecomastia

9. a. Mastitis occurs during lactation and is caused by Staphylococcus aureus. Ductal ectasia involves subareolar area ducts and has multicolored sticky nipple discharge and inflammatory signs. It is not associated with malignancy. Fibroadenoma occurs in 10% of women ages 15 to 40 and has well-delineated, very mobile tumors. A biopsy must be done to exclude malignancy. Senescent gynecomastia occurs in older men, probably from increased conversion of androgens to estrogens in peripheral circulation. It generally regresses in 6 to 12 months.

7. A 50-year-old patient is preparing to begin breast cancer treatment with tamoxifen (Nolvadex). What point should the nurse emphasize when teaching the patient about her new drug regimen? A "You may find that your medication causes some breast sensitivity." B "It's important that you let your care provider know about any changes in your vision." C "You'll find that this drug often alleviates some of the symptoms that accompany menopause." D "It's imperative that you abstain from drinking alcohol after you begin taking tamoxifen."

B 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, and it is not necessary for the patient to abstain from alcohol.

8. 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 considered a precursor to cancer. C Unexpected nipple discharge of any type warrants medical follow-up. D Galactorrhea is a normal age-related change and a frequent perimenopausal symptom.

C 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.

1. 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.

3. The nurse performs a breast examination on a 68-year-old female patient. Which clinical manifestation, if assessed by the nurse, indicates that further evaluation for breast cancer is needed? Bilateral pendulous breasts Right breast is warm, painful to touch Irregular, nontender lump with induration Palpable lump that is tender and movable

C Clinical 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.

5. The nurse is caring for an obese 67-year-old woman after a right mastectomy with axillary lymph node dissection. Which should the nurse include in the discharge instructions? "Arm exercises should not be started for 4 to 6 weeks." "Discontinue arm exercises if you have discomfort or pain." "Special massage therapy can decrease swelling in your arm." "Keep your right arm in a sling to decrease pain and swelling."

C 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.

4. The nurse is caring for a 52-year-old woman with breast cancer who is receiving high-dose doxorubicin (Adriamycin). Which assessment is most important for the nurse to make? Observe for alopecia. Determine visual acuity. Monitor cardiac rhythm. Assess mouth and throat.

C Doxorubicin (especially at high doses) may cause cardiotoxicity and heart failure. The nurse should monitor for cardiac dysrhythmias, electrocardiogram changes, and clinical 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.

4. A 29-year-old primiparous patient has a 3-week-old infant whom she is breastfeeding. The woman has sought care because of recent breast tenderness, redness, and fever. Which teaching point should the nurse prioritize when following up her care? A Encourage patient to continue breastfeeding her infant. B Refer patient for a mammogram as quickly as possible. C Ensure patient adheres to her prescribed antibiotic regimen. D Teach patient to use warm compresses and educate her about self-limiting nature of illness.

C Mastitis normally requires antibiotic therapy, the success of which is often dependent on close adherence to the prescribed regimen. Breastfeeding should indeed be continued if possible, but effective treatment of her infection would be the immediate priority. If a palpable mass develops, the patient should obtain medical follow-up because she may be developing an abscess. Mastitis is not necessarily self-limiting, and mammography is not normally indicated.

2. The nurse caring for patients in a primary care clinic identifies which patient as being the most at risk for the development of breast cancer? A 25-year-old female with fibrocystic breast disease A 59-year-old male who has inherited the APC gene A 72-year-old female with a family history of breast cancer A 43-year-old male 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. Mutations in BRCA genes may cause 5% to 10% of breast cancers; 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.

12. The patient with breast cancer has a left mastectomy with axillary node dissection. Ten lymph nodes are resected with three positive for malignant cells. The patient has stage IIB breast cancer. What is the best nursing intervention to use in planning care? Evaluate left arm lymphatic accumulation. Maintain joint flexibility and left arm function. Teach her about chemotherapy and radiation therapy. 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 for this patient. The approach for the care of the left arm and teaching the patient about further therapy will be based on this assessment.

5. A 51-year-old woman has 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.

1. The nurse teaches a 53-year-old patient about screening for early detection of breast cancer. Which statement by the patient requires an intervention by the nurse? "I should plan to have a mammogram every year." "I will see a health care provider every year for a breast examination." "A breast examination should be done right after my menstrual period." "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 40 and clinical breast examination every year at age 40. An alternative suggestion is to begin screening mammograms at age 50. Breast self-examination has benefits and limitations and may not be a reliable method for early detection of breast cancer. BSE is optional but should be done in premenopausal women right after the menstrual period when the breasts are less lumpy and tender.