Care of Patients with Breast Disorders Chapter 73

20. The client has large breasts. Which health problem is she most likely to develop? a. Increased breast tenderness b. Increased libido c. Chest pain d. Back pain

ANS: D The added weight of large breasts and the altered center of gravity increase spinal pull and contribute to back pain. She is not at risk for developing increased breast tenderness, increased libido, or chest pain.

10. Which is the priority nursing diagnosis for the client with advanced breast cancer and bone metastasis? a. Acute Pain b. Impaired Mobility c. Risk for Infection d. Imbalanced Nutrition: Less than Body Requirements

ANS: A Bone metastasis can cause intense continuous pain that disrupts the client's activities and sleep and decreases the client's quality of life. This problem should be managed ahead of all other problems. Although the client may also be experiencing impaired mobility, a risk for infection, and an imbalance in nutrition, none of these problems will be as disruptive as acute pain. The pain must become manageable before the other problems can be addressed.

11.The client who has recently had a mastectomy for breast cancer is crying as a nurse enters the room. When asked why she is crying, the client responds, "I know I shouldn't cry because this surgery may save my life, but I know that I will never look the same." Which is the nurse's best response? a. "It is all right to cry. Mourning this loss is important in getting past this point." b. "You're right. It is silly to carry on like this when a prosthesis is available." c. "Would you like to talk to a client who has had a mastectomy and is coping well?" d. "How have you coped with difficult situations in the past?" ANS: A Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy part of adapting or adjusting to a new image. The other answer options do not address the client's need to grieve before being able to cope.

ANS: A Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy part of adapting or adjusting to a new image. The other answer options do not address the client's need to grieve before being able to cope.

1.Which statement made by the client who has recently had a mammogram indicates a need for clarification regarding the importance or purpose of this procedure? a. "Now that I have had a mammogram, my risk for getting breast cancer is reduced." b. "Now that I've had a mammogram, I will still do a breast self-examination monthly." c. "Yearly mammograms can reduce my risk of dying from breast cancer." d. "The amount of radiation exposure from a mammogram is very low."

ANS: A Regular or yearly mammography does not decrease the incidence of breast cancer. It only assists in early detection and diagnosis and decreases the mortality rate from breast cancer. The client should be instructed that the mammogram uses a very small amount of radiation in the test, and that consistent scheduling of a mammogram, along with a breast self-examination performed at least monthly, can reduce the client's risk of dying from breast cancer.

15. The client asks how soon after a mastectomy she can engage in sexual activity. Which is the nurse's best response? a. "You may engage in sexual activity as soon as you are comfortable." b. "You should wait until 3 months have passed before resuming sexual activity." c. "You may safely engage in sexual activity as soon as the incision has healed completely." d. "You should undergo counseling or therapy before you consider having sex again."

ANS: A Sexual intercourse can be resumed whenever the client is comfortable. Until the incision is healed, clients should be taught how to protect the incision and avoid contact with the surgical site during intercourse. The client will not necessarily have to wait 3 months or undergo counseling before engaging in sexual activity.

2.When performing a clinical breast examination on a client, a nurse palpates a thickened area where the skin folds under the breast. Which is the nurse's best action? a. Proceeding with the examination b. Determining if the thickness is bilateral c. Asking the client how long the thickness has been present d. Attempting to elicit the same response with the client in a different position

ANS: A The presence of a thickened area where the skin folds under the breast is the inframammary ridge, a normal anatomic finding. Clients should be taught to identify this ridge and not confuse it with the presence of a lump or abnormal tissue thickening. Because this is a normal finding, there is no reason to be concerned if it is present bilaterally or occurs in a different position, or how long the finding has been notable.

7.The client who has recently been diagnosed with invasive infiltrating ductal carcinoma asks what this means. Which is the nurse's best response? a. "The cancer has spread from the breast ducts into surrounding breast tissue." b. "The cancer has spread from the breast into local lymph nodes and channels." c. "The cancer has spread from the breast into surrounding tissues and organs." d. "The cancer has spread from the breast into distant tissues and organs."

ANS: A The term invasive, when applied to infiltrating ductal carcinoma, means that the cancer cells are no longer confined to ductal tissue but have spread into surrounding breast tissue. This term alone, however, does not indicate that the disease has spread beyond the breast itself. Therefore, the other answer options are incorrect because they indicate that the cancer has spread beyond the breast.

6. Which statement made by a client about breast cancer indicates correct understanding of the disease? a. "Breast cancer is the leading cause of cancer deaths among women in the United States." b. "Breast cancer is the leading type of cancer among women in North America." c. "Late onset of menses and early menopause increase the risk for breast cancer." d. "The incidence of breast cancer decreases with age."

ANS: B Breast cancer is the most common form of cancer diagnosed in women and is the second leading cause of cancer deaths in women in the United States. The incidence of breast cancer increases with age. Late onset of menses and early menopause do not necessarily increase the risk for breast cancer.

16. Which exercise plan or activity should the nurse teach the client for the first postoperative day after a modified radical mastectomy? a. "Perform no movement or exercise today. Keep the arm supported and elbow flexed, and as close to your body as possible." b. "Without moving your shoulder, straighten your elbow three times hourly and squeeze a rubber ball with your fingers." c. "Face the wall and extend your arm straight out to the wall. Walk your fingers as far above your head as your arm will reach and then walk them back down." d. "Hold your operative arm straight out from the shoulder to the side. Use your nonoperative arm to pull the operative arm completely straight above your head."

ANS: B Mild exercise begins the first postoperative day. The exercises should not put stress on the incision and do not involve the shoulder at this point. Full extension of the elbow, with support, is important, as is using grip maneuvers for the hand on the affected side.

12. A nurse empties 40 mL of sanguineous drainage from the Jackson-Pratt drain in the client's incision on the first day after a mastectomy and axillary node dissection. Which other actions regarding the drain will be high priority for the nurse? a. Flushing the tubing with urokinase to ensure patency b. Compressing and close the drain to ensure suction c. Advancing the tubing 1/2 inch from the insertion site d. Clamping the drain for 2 hours and releasing the clamp for 2 hours

ANS: B The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be compressed and closed to create suction as it slowly re-expands. The drain should never be flushed with urokinase, tubing should not be advanced, and the drain should not be clamped and released for 2 hours.

24. The client has undergone breast reconstructive surgery. The nurse is developing a postoperative teaching plan for the client. Which teaching strategy will be highest priority? a. Remind the client that optimal appearance may not occur for 1 year. b. Remind the client that she should continue her monthly breast self-examination. c. Remind the client that full activity will probably not be able to be resumed for 12 weeks. d. Remind the client that she will no longer have to schedule mammograms annually.

ANS: B The client should still perform monthly breast self-examinations and schedule annual mammograms. Optimal appearance may be achieved by 6 months. The client should ask the physician if full activity can be resumed at the 6-week appointment.

17. The client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates correct understanding for managing this problem? a. "I will reduce my intake of salt." b. "I will elevate my arm on a pillow at night." c. "I will try to drink at least 3 L of water each day." d. "I will wear long sleeves to prevent sun exposure to this arm."

ANS: B The formation of edema is aggravated by having the arm in a position dependent to the heart. Elevating the arm as much as possible assists gravity to promote better venous and lymph return. This will be a more effective intervention than salt reduction or drinking large amounts of water. Preventing sun exposure will have no effect on the lymphedema.

5. Which client should the nurse encourage to seek genetic counseling regarding her risk for BRCA1 or BCRA2 gene mutation-related breast cancer? a. A woman whose father had lung cancer, mother had leukemia, and sisters have skin cancer b. A woman whose brother and sister have breast cancer and whose mother has ovarian cancer c. A woman whose fraternal twin sister has breast cancer d. A woman who has bilateral benign breast disease

ANS: B The most well-defined increased genetic risk for breast cancer is related to mutations in the BRCA1 or BRCA2 gene. Families in which either of these genes is mutated have higher rates of breast and ovarian cancer in first-degree relatives. The other answer selections do not have increased rates of breast and ovarian cancer in first-degree relatives

22. Which client will be most likely to benefit from hormonal therapy as a chemotherapeutic option? a. The premenopausal client who has a HER2/neu positive breast cancer b. The premenopausal client whose main estrogen source is the ovaries c. The postmenopausal client who has no history of cardiac disease d. The postmenopausal client who is not concerned about fertility

ANS: B The premenopausal client with her ovaries as the main estrogen source may most benefit from hormonal therapy. The client with HER2/neu-positive breast cancer would probably benefit from targeted therapy. Postmenopausal clients will be less likely to receive any benefit from hormonal therapy.

2.Which factors are considered to be indicative of a moderate increased risk of a client developing breast cancer? (Select all that apply.) a. Female gender b. High postmenopausal bone density c. Ionizing radiation d. Family history of one first-degree relative e. Genetic factors f. First child born after age 30 g. Biopsy-confirmed atypical hyperplasia h. Oral contraceptives

ANS: B, C, D, G Factors considered to be indicative of a moderate increased risk of a client developing breast cancer include high postmenopausal bone density, ionizing radiation, family history of one first-degree relative, and biopsy-confirmed atypical hyperplasia. Female gender and genetic factors are indicative of high increased risk. The first child born after age 30 and oral contraceptives are indicative of low increased risk of developing breast cancer.

MULTIPLE RESPONSE 1.When assessing the client with ductal ectasia, the nurse understands that signs and symptoms supporting this diagnosis include which of the following? (Select all that apply.) a. A soft mass on palpation b. Greenish-brown nipple discharge c. Enlarged axillary nodes d. A mass with regular borders e. Redness and edema over the site of the mass f. Mass tenderness on palpation

ANS: B, C, E, F The benign condition, ductal ectasia, is caused by dilation and thickening of collecting ducts in the subareolar area. It results in activation of the inflammatory response when the ducts fill with cellular debris. Clinical manifestations of this condition include development of a hard mass with irregular borders that is tender on palpation. A greenish-brown nipple discharge, enlarged axillary nodes, and redness and edema over the site of the mass are also noted. Palpation of a soft mass or a mass with regular borders is not applicable to ductal ectasia.

23. The client is being treated with an aromatase inhibitor to treat her breast cancer. The nurse is developing a plan of care for the client. Which intervention will be highest priority? a. Monitoring the client closely for evidence of depression b. Monitoring the client closely for evidence of menopausal symptoms c. Monitoring the client closely for evidence of osteoporosis d. Monitoring the client closely for evidence of weight gain

ANS: C A major side effect of the aromatase inhibitors is loss of bone density. There is no evidence that depression, menopausal symptoms, or weight gain are primary side effects of the aromatase inhibitors.

4.The client has just been diagnosed with fibrocystic breast disease. She asks what this means in terms of her health. Which is the nurse's best response? a. "This increases your risk for breast cancer, so you'll need to schedule yearly mammograms." b. "This will progressively increase as you age, especially if you have never been pregnant." c. "This will probably diminish with menopause if you don't take replacement hormones." d. "This is genetic and you should teach your daughters about it."

ANS: C Although the cause of fibrocystic breast changes is unknown, the condition seems to be related to normal fluctuations in estrogen levels during the menstrual cycle. Symptoms usually resolve after menopause in the absence of estrogen supplementation. The presence of fibrocystic breast changes does not necessarily increase the client's risk for breast cancer, will not necessarily increase with age, and does not routinely have a genetic component.

19. The client has recently been diagnosed with a mass in her breast. Which characteristic of a breast lump or mass is more associated with breast cancer than with benign breast disease? a. Lump or mass present in same area of both breasts b. Pain or discomfort caused by palpation c. Attached firmly to the chest wall d. Appeared suddenly with no additional symptoms

ANS: C Malignant tumors are usually nonmobile and often attached to the chest wall, rather than to breast tissue. The other answer options do not list characteristics clearly associated with benign or malignant masses.

21. The client is undergoing treatment for breast cancer and tells the nurse that she is considering taking ginger capsules to help her deal with chemotherapy-induced nausea. Which will be the most appropriate response by the nurse? a. "I think that's a good idea. Make sure that you keep a symptom diary while you're taking the ginger." b. "I don't think that ginger will have much of an effect on your symptoms." c. "The ginger probably won't be harmful, but it would be best if you discussed this with your doctor." d. "Which led you to consider taking ginger capsules as an option?"

ANS: C Studies are being done on the effect of ginger on chemotherapy-induced nausea. However, always before trying any complementary or alternative therapy, the client should consult her physician.

13. The client is postoperative from a left-sided mastectomy. She says that the incision and the inner side of her arm from the armpit to the elbow are numb. Which is the nurse's best action? a. Teaching the client to avoid lifting heavy objects b. Measuring the circumference of the client's left arm c. Documenting it and reassuring the client that it is an expected finding d. Reassuring the client that the surgeon will be notified of the assessment findings

ANS: C The nerves supplying the skin in the area were injured during surgery, decreasing sensation to the area. These problems frequently resolve over time. Teaching the client to avoid lifting heavy objects or measuring the circumference of the arm will not improve the sensation to the client's arm. There is no reason to notify the surgeon about normal findings.

9.Which pathologic description of a breast cancer would the nurse interpret as being most indicative of the best prognosis for long-term survival? a. Poorly differentiated; 20% of cells in S phase; estrogen receptor-negative b. Moderately differentiated; 50% of cells in S phase; estrogen receptor-negative c. Undifferentiated; 50% of cells in S phase; estrogen receptor-positive d. Highly differentiated; 10% of cells in S phase; estrogen receptor-positive ANS: D Lower grade malignancies are slower growing (have a smaller percentage of cells in the S phase) and more closely resemble the differentiated breast tissue from which they arose. Estrogen receptor-positive tumors respond better to adjuvant therapy, and the client usually has a longer survival rate. Cancer cells that are poorly or moderately differentiated or undifferentiated have a decreased prognosis, as do estrogen receptor-negative tumors

ANS: D Lower grade malignancies are slower growing (have a smaller percentage of cells in the S phase) and more closely resemble the differentiated breast tissue from which they arose. Estrogen receptor-positive tumors respond better to adjuvant therapy, and the client usually has a longer survival rate. Cancer cells that are poorly or moderately differentiated or undifferentiated have a decreased prognosis, as do estrogen receptor-negative tumors

8.Which comment made by the client with breast cancer indicates correct understanding regarding cancer causes and prevention? a. "I will cure my cancer by eating a low-fat diet from now on." b. "If I had breast-fed my children, this would not have happened to me." c. "I hope this doesn't increase my risk for bone cancer or lung cancer." d. "I will have regular mammograms on my other breast to detect cancer early."

ANS: D Regular mammography can help detect breast cancer at an early stage. Women who have had breast cancer have a greater risk of developing cancer in the other breast.

14. The client receiving tamoxifen (Tamofen) asks how this therapy helps fight breast cancer. Which is the nurse's best response? a. "Breast cancer cells need estrogen to continue growing. This agent decreases estrogen levels." b. "Breast cancer cells need estrogen. The drug causes you to secrete testosterone, not estrogen." c. "Breast cancer cells need estrogen. The drug kills estrogen-secreting cells and cancer cells." d. "The drug blocks estrogen receptors, reducing the availability of estrogen to breast cancer cells."

ANS: D Tamoxifen is an estrogen antagonist-agonist. Its use in breast cancer is limited to cancers that express the estrogen receptor. Tamoxifen binds to the estrogen receptors, inhibiting the binding of estrogen to the receptors and therefore "starving" the cancer cells of an essential growth factor. The drug does not decrease the circulating levels of estrogen, does not cause testosterone to be secreted instead of estrogen, and does not kill off estrogen-secreting cells.

18. At what stage in a woman's life does the American Cancer Society recommend that she begin performing monthly breast self-examination (BSE)? a. At menarche b. At onset of sexual activity c. At onset of menopause d. At onset of young adulthood

ANS: D The American Cancer Society recommends that all women begin performing a monthly breast self-examination no later than age 20. The onset of menarche, sexual activity, or menopause will not necessarily change the outcome of a breast self-examination.

3.The client who has discovered a lump in her breast becomes tearful when scheduling a mammogram. Which is the nurse's best response? a. "It is a good thing you called. All lumps are considered cancerous until proven otherwise." b. "Unless you have a relative with breast cancer, this lump is probably benign." c. "Diagnosing cancer at this early stage is most likely to result in a cure." d. "Many women have breast lumps, and 90% of the lumps are benign."

ANS: D The finding of a breast lump or mass is a frightening experience. Clients should be reassured, until they can be seen or testing is done, that 90% of all breast lumps or masses are benign. It is inaccurate for the nurse to state that all lumps are considered cancerous until proven benign, the lump is probably benign unless the client has a relative with breast cancer, or diagnosing cancer at an early stage usually results in a cure.