Chpt 51 - Breast Disorders

14. Which information will the nurse include in patient teaching for a 36-yr-old patient who is scheduled for stereotactic core biopsy of the breast? a. A local anesthetic 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 anesthetic is given before stereotactic biopsy. NPO status is not needed because no sedative drugs are given. The patient is placed in the prone position. A biopsy gun is used to obtain the specimens. DIF: Cognitive Level: Apply (application) REF: 1206 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A patient diagnosed with breast cancer asks the nurse what "triple negative" means. An accurate response from the nurse about triple-negative breast cancer should include that a. the tumor is not likely to be responsive to hormone therapy. b. HER-2 receptor testing was repeated for a total of three samples. c. treatment with chemotherapy is not likely to be recommended. d. estrogen receptor testing identified the three hormones causing the cancer.

ANS: A A patient whose breast cancer tests negative for all three receptors (estrogen, progesterone, and HER-2) has triple-negative breast cancer. These cancers do not usually respond to hormone therapy or therapy for the human epidermal growth factor receptor 2 (HER-2). Chemotherapy appears to have the most success in treating triple-negative breast cancer. DIF: Cognitive Level: Apply (application) REF: 1211 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

3. A 51-yr-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that a. FNA is done in the outpatient clinic, and results are available in 1 to 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 to 48 hours. (Page 1205. FNA biopsy is performed by inserting a needle into a lesion to sample fluid from a breast cyst, remove cells from intercellular spaces, or sample cells from a solid mass. Before the procedure, the breast area is first locally anesthetized. Then the needle is placed into the breast, and fluid and cells are aspirated into a syringe. Three or four passes are usually made. If the results are negative with a suspicious lesion, an additional biopsy may be necessary.) No incision is needed. FNA may be guided by ultrasound but not by mammogram. Because the immobility of the breast lump suggests cancer, further testing will be done if the FNA results are negative. DIF: Cognitive Level: Apply (application) REF: 1206 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. The nurse will anticipate teaching a patient who is diagnosed with lobular carcinoma in situ (LCIS) about a. tamoxifen c. lymphatic mapping. b. lumpectomy. d. MammaPrint testing.

ANS: A Tamoxifen is used as a chemopreventive therapy in some patients with LCIS. The other diagnostic tests and therapies are not needed because LCIS does not usually require treatment. DIF: Cognitive Level: Apply (application) REF: 1217 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

8. After a 48-yr-old patient has had a modified radical mastectomy (removal of breast and pectoralis muscle with ALND), the pathology report identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to teach the patient about a. tamoxifen b. estradiol (Estrace). c. raloxifene (Evista). d. trastuzumab (Herceptin).

ANS: A Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. (Tamoxifen blocks estrogen receptors (ERs). Drug Alert: Tamoxifen • Irregular vaginal bleeding or spotting may occur. • Decreased visual acuity, corneal opacity, and retinopathy can occur in women receiving high doses (240-320 mg/day for >17 mo). These problems may be irreversible. • Instruct patient to immediately report decreased visual acuity. • Monitor for signs of deep vein thrombosis, pulmonary embolism, and stroke, including shortness of breath, leg cramps, and weakness. 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 tumors. Trastuzumab is used to treat tumors that have the HER-2 receptor. DIF: Cognitive Level: Apply (application) REF: 1217 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

28. When using the accompanying illustration to teach a patient about breast self-examination, the nurse will include the information that most breast cancers are located in which part of the breast? a. 1 b. 2 c. 3 d. 4 e. 5

ANS: A The upper outer quadrant is the location of most of the glandular tissue of the breast. DIF: Cognitive Level: Understand (comprehension) REF: 1212 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

26. A patient who is scheduled for a lumpectomy and axillary lymph node dissection tells the nurse, "I would rather not know much about the surgery." Which response by the nurse is best? a. "Tell me what you think is important to know about the surgery." b. "It is essential that you know enough to provide informed consent." c. "Many patients do better after surgery if they have more information." d. "You can wait until after surgery for teaching about pain management."

ANS: A This response shows sensitivity to the individual patient's need for information about the surgery. The other responses are also accurate, but the nurse should tailor patient teaching to individual patient preferences. DIF: Cognitive Level: Analyze (analysis) REF: 1218 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

22. A 36-yr-old patient who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic reporting symptoms. Which information is likely to change the treatment plan? a. There is yellow discharge from the patient's right nipple. b. An area on the breast is hot, pink, and tender to the touch. c. Firm, moveable lumps are in the upper outer breast quadrants. d. The lumps get more painful before the patient's menstrual period.

ANS: B An area that is hot or pink suggests an infectious process such as mastitis, which would require further assessment and treatment. Manifestations of fibrocystic breast changes include one or more palpable lumps that are often round, well delineated, and freely movable within the breast. Discomfort ranging from tenderness to pain may also occur. The lump is usually observed to increase in size and perhaps in tenderness before menstruation. Nipple discharge associated with fibrocystic breasts is often milky, watery-milky, yellow, or green. DIF: Cognitive Level: Apply (application) REF: 1206 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. Which action will the nurse include in the plan of care for a patient with right arm lymphedema? a. Avoid isometric exercise on the right arm. b. Assist with application of a compression sleeve. c. Keep the right arm at or below the level of the heart. d. Check blood pressure (BP) on both right and left arms.

ANS: B 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 patient's left arm. The arm should not be placed in a dependent position. DIF: Cognitive Level: Apply (application) REF: 1220 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. A 58-yr-old woman tells the nurse, "I understand that I have stage II breast cancer and I need to decide on a surgery, but I feel overwhelmed. What do you think I should do?" Which response 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 a decision about your health." d. "There is no need to make a decision rapidly; you have time to think about this."

ANS: B Inquiring about the patient's understanding shows the nurse's willingness to assist the patient with the decision-making process without imposing the nurse's values or opinions. (Table 51-5 - Interprofessional Care) Treatment decisions for breast cancer do need to be made relatively quickly. Imposing the nurse's opinions or showing an unwillingness to discuss the topic could cut off communication. DIF: Cognitive Level: Apply (application) REF: 1221 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

4. Which assessment finding in a 36-yr-old patient is most indicative of a need for further evaluation? a. Bilateral breast nodules that are tender with palpation b. A breast nodule that is 1 cm in size, nontender, and fixed c. A breast lump that increases in size before the menstrual period d. A breast lump that is small, mobile, with a rubbery consistency

ANS: B Painless and fixed lumps suggest breast cancer. (If palpable, breast cancer is characteristically hard and may be irregularly shaped, poorly delineated, nonmobile, and nontender. P1211) The other findings are more suggestive of benign processes such as fibrocystic breasts and fibroadenoma. DIF: Cognitive Level: Apply (application) REF: 1212 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. The nurse is providing preoperative teaching about the transverse rectus abdominis musculocutaneous (TRAM) procedure to a patient. Which information will the nurse include? a. Saline-filled implants are placed under the pectoral muscles. b. Recovery from the TRAM surgery takes at least 6 to 8 weeks. c. Muscle tissue removed from the back is used to form a breast. d. TRAM flap procedures may be done in outpatient surgery centers.

ANS: B Patients take at least 6 to 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: Apply (application) REF: 1223 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. Which patient statement indicates that the nurse's teaching about tamoxifen has been effective? a. "I can expect to have leg cramps." b. "I will call if I have any eye problems." c. "I should contact you if I have hot flashes." d. "I will be taking the medication for 6 to 12 months."

ANS: B Retinopathy, cataracts, and decreased visual acuity should be immediately reported because it is likely that the tamoxifen will be discontinued or decreased. Tamoxifen treatment generally lasts 5 years. Hot flashes are an expected side effect of tamoxifen. Leg cramps may be a sign of deep vein thrombosis, and the patient should immediately notify the health care provider if pain occurs. DIF: Cognitive Level: Apply (application) REF: 1217 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

17. Which information should the nurse include in teaching a patient who is scheduled for external beam radiation to the breast? a. The radiation therapy will take a week to complete. b. Careful skin care in the radiated area will be necessary. c. Visitors are restricted until the radiation therapy is completed. d. Wigs may be used until the hair regrows after radiation therapy.

ANS: B Skin care will be needed because of the damage caused to the skin by the radiation. External beam radiation is done over a 5- to 6-week period. Scalp hair loss does not occur with breast radiation therapy. Because the patient does not have radioactive implants, no visitor restrictions are necessary. DIF: Cognitive Level: Apply (application) REF: 1216 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. The nurse notes bilateral enlargement of the breasts during examination of a 62-yr-old male patient. Which action should the nurse take first? a. Refer the patient for mammography. b. Question the patient about current medications. c. Explain that this is temporary due to hormonal changes. d. Teach the patient how to palpate the breast tissue for lumps.

ANS: B The first action should be further assessment. Because gynecomastia is a possible side 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: Apply (application) REF: 1209 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. The nurse provides discharge teaching for a 61-yr-old patient who has had a left modified radical mastectomy and lymph node dissection. Which statement by the patient indicates that teaching has been successful? a. "I will need to use my right arm and to rest the left one." b. "I will avoid reaching over the stove with my left hand." c. "I will keep my left arm in a sling until the incision is healed." d. "I will stop the left arm exercises if moving the arm is painful."

ANS: B The patient should avoid any activity that might injure the left arm, such as reaching over a burner. If the left arm exercises are painful, analgesics should be used and the exercises continued in order to restore strength and range of motion. The left arm should be elevated at or above heart level and should be used to improve range of motion and function. DIF: Cognitive Level: Apply (application) REF: 1215 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

11. A 33-yr-old patient has a saline breast implant inserted in the outpatient surgery area. Which instruction will the nurse include in the discharge teaching? a. Take aspirin every 4 hours to reduce inflammation. b. Check wound drains for excessive blood or a foul odor. c. Wear a loose-fitting bra to decrease irritation of the sutures. d. Resume normal activities 2 to 3 days after the mammoplasty.

ANS: B The patient 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 to 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: Apply (application) REF: 1219 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A 53-yr-old woman who is experiencing menopause is discussing the use of hormone therapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide? a. HT is a safe therapy for menopausal symptoms if there is no family history of BRCA genes. b. HT does not appear to increase the risk for breast cancer unless there are other risk factors. c. The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer. d. Natural herbs are as effective as estrogen in relieving symptoms without increasing the risk of breast cancer.

ANS: C Because HT has been linked to increased risk for breast cancer, the patient and health care provider must determine whether or not to use HT. (Table 51-2 Hormone use is a Risk Factor for Breast Cancer, especially in postmenopausal women). Breast cancer incidence is increased in women using HT, independent of other risk factors. HT 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: Apply (application) REF: 1217 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. The nurse is caring for a patient with breast cancer who is receiving chemotherapy with doxorubicin and cyclophosphamide. Which assessment finding is most important to communicate to the health care provider? a. The patient complains of fatigue. b. The patient eats only 25% of meals. c. The patient's apical pulse is irregular. d. The patient's white blood cell (WBC) count is 5000/µL.

ANS: C Doxorubicin can cause cardiac toxicity. The dysrhythmia should be reported because it may indicate a need for a change in therapy. Anorexia, fatigue, and a low-normal WBC count are expected effects of chemotherapy. DIF: Cognitive Level: Analyze (analysis) REF: 1217 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. During a well-woman physical examination, a 43-yr-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask? a. "Do you currently smoke tobacco?" b. "Have you ever had a breast injury?" c. "At what age did you start having menstrual periods?" d. "Is there a 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. Table 51-2 Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk. DIF: Cognitive Level: Apply (application) REF: 1209 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes? a. Obtain a permanent breast prosthesis before the patient is discharged from the hospital. b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes. c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. d. Insist that the patient examine the surgical incision when the initial dressings are removed.

ANS: C The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery. DIF: Cognitive Level: Apply (application) REF: 1220 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

13. A patient newly diagnosed with stage I breast cancer is discussing treatment options with the nurse. Which statement by the patient indicates that additional teaching may be needed? a. "There are several options that I can consider for treating the cancer." b. "I will probably need radiation to the breast after having the surgery." c. "Mastectomy is the best choice to decrease the chance of cancer recurrence." d. "I can probably have reconstructive surgery at the same time as a mastectomy."

ANS: C The survival rates with lumpectomy and radiation or modified radical mastectomy are comparable. The other patient statements indicate a good understanding of stage I breast cancer treatment. DIF: Cognitive Level: Apply (application) REF: 1213 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

27. The outpatient clinic receives telephone calls from four patients. Which patient should the nurse call back first? a. A 57-yr-old patient with ductal ectasia who has sticky multicolored nipple discharge and severe nipple itching b. A 21-yr-old patient with a family history of breast cancer who wants to discuss genetic testing for the BRCA gene c. A 40-yr-old patient who still has left side chest and arm pain 2 months after a left modified radical mastectomy d. A 50-yr-old patient with stage 2 breast cancer who is receiving doxorubicin and has ankle swelling and fatigue

ANS: D Although all the patients have needs that the nurse should address, the patient who is receiving a cardiotoxic medication and has symptoms of heart failure should be assessed by the nurse first. BRCA testing may be appropriate for the 21-yr-old patient, but it does not need to be done immediately. Chest and arm pain are normal up to 3 months after mastectomy. Nipple discharge and itching is a common finding with ductal ectasia. DIF: Cognitive Level: Analyze (analysis) REF: 1217 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

19. The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph node dissection. Which action should the nurse take first? a. Teach the patient 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 patient to describe what she knows about the surgery.

ANS: D Before teaching, the nurse should assess the patient's current knowledge level. The other teaching also may be appropriate, depending on the assessment findings. DIF: Cognitive Level: Analyze (analysis) REF: 1218 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. A patient has had left-sided lumpectomy (breast-conservation surgery) and an axillary lymph node dissection. Which nursing intervention is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Teaching the patient how to avoid injury to the left arm b. Assessing the patient's range of motion for the left arm c. Evaluating the patient's understanding of instructions about drain care d. Administering an analgesic 30 minutes before scheduled arm exercises

ANS: D LPN/LVN education and scope of practice include administration and evaluation of the effects of analgesics. Assessment, teaching, and evaluation of a patient's understanding of instructions are more complex tasks that are more appropriate to RN level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 1220 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

20. When the nurse is working in the women's health care clinic, which action is appropriate to take? a. Teach a healthy 30-yr-old patient about the need for an annual mammogram. b. Discuss scheduling an annual clinical breast examination with a 22-year-old patient. c. Explain to a 60-yr-old patient that mammography frequency can be reduced to every 3 years. d. Teach a 28-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI).

ANS: D MRI (in addition to mammography) is recommended for women who are at high risk for breast cancer. A woman should have a clinical breast examination about every 3 years for women in their 20s and 30s and every year for women age 40 years and older. Annual mammograms are recommended for women older than 40 years of age. DIF: Cognitive Level: Apply (application) REF: 1205 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

1. The nurse teaching a young women's community service group about breast self-examination (BSE) will include that a. BSE will reduce the risk of dying from breast cancer. b. BSE should be done daily while taking a bath or shower. c. annual mammograms should be scheduled in addition to BSE. d. performing BSE after the menstrual period is more comfortable.

ANS: D Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. The evidence is not clear that BSE reduces mortality from breast cancer. BSE should be done monthly. Annual mammograms are not routinely scheduled for women younger than age 40 years, and newer guidelines suggest delaying them until age 50. Page 1205 DIF: Cognitive Level: Apply (application) REF: 1205 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

7. The nurse will teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin) that a. hot flashes may occur with the medication. b. serum electrolyte levels will be drawn monthly. c. the patient will need frequent eye examinations. d. the patient should call if she notices ankle swelling.

ANS: D Trastuzumab can lead to ventricular dysfunction, so the patient is taught to self-monitor for symptoms of heart failure. Drug Alert: Trastuzumab (Herceptin) pg 1217 • Use with caution in women with preexisting heart disease. • Monitor for signs of ventricular dysfunction and heart failure. There is no need to monitor serum electrolyte levels. Hot flashes or changes in visual acuity may occur with tamoxifen, but not with trastuzumab. DIF: Cognitive Level: Apply (application) REF: 1218 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity