Chapter 54: Caring for Clients with Breast Disorders

A client has been diagnosed with breast cancer and is awaiting cytology results of a biopsy. During client education, the nurse discusses the possible types of breast malignancies. Which is the most common type?

ductal The most common malignancy is ductal carcinoma (80%); followed by infiltrating lobular carcinoma (10%); medullary carcinoma, mucinous carcinoma, and tubular ductal carcinoma; and inflammatory breast cancer, the rarest but most aggressive form of breast cancer.

A client has been diagnosed with stage II breast cancer. The client tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The client's husband has done some online research and is asking why his wife does not have a modified radical mastectomy "to be sure all the cancer is gone." What would be the nurse's best response?

"According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy." Breast conservation along with radiation therapy in stage I and stage II breast cancer results in a survival rate equal to that of modified radical mastectomy. Mastectomies are still necessary in many cases, but are not associated with particular risk of recurrence.

A woman with a 3-cm breast tumor is scheduled for a lumpectomy followed by 5 to 7 weeks of radiation therapy. The patient asks the nurse if this procedure would cure her. What is the nurse's best response?

"Lumpectomy, followed by radiation, has the same predicted long-term survival rates as a mastectomy." The best response is to provide accurate information that won't increase anxiety. Choice "D" is also correct information but, according to limited research, less than 20% of women have recurrences that require a mastectomy. Providing this information before surgery is not recommended.

A client has had a total mastectomy with immediate reconstruction. The client asks the nurse when she can take a shower. What should the nurse respond?

"Not until the drain is removed" If immediate reconstruction has been performed, showering may be contraindicated until the drain is removed.

The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The client states, "My doctor and I talked about tamoxifen to help prevent breast cancer. Do you think it will work?" What would be the nurse's best response?

"Tamoxifen is known to be a highly effective protective measure." Tamoxifen has been shown to be a highly effective chemopreventive agent. However, it cannot reduce the risk of cancer by 100%. It also acts to prevent osteoporosis.

The nurse is educating a patient about the best time to perform breast self-examination (BSE). When does the nurse inform her is the best time after menses to perform BSE?

5 to 7 days Most women notice increased tenderness and lumpiness before their menstrual periods; therefore, BSE is best performed after menses (day 5 to day 7, counting the first day of menses as day 1).

A client has fibrocystic breast disease. Assuming that there are no sudden or unusual changes, the nurse would suggest that the client have follow-up appointments with her physician every ____ months. Record your answer with a whole number.

6 The nurse encourages the client to schedule a breast examination with a physician every 6 months or whenever a new or unusual lump develops.

A 42-year-old client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this client's lump is cancerous?

A nonmobile mass with irregular edges Breast cancer tumors are typically fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction, not eversion, may be a sign of cancer.

A client who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. During the nurse's admission assessment, the nurse observes that the client is distracted and tense. What is the nurse's best action?

Acknowledge the fear the client is likely experiencing. In the breast cancer diagnostic phase, it is appropriate to acknowledge the client's feelings of fear, concern, and apprehension. This must precede interventions such as referrals, if appropriate. Assessment of stress management skills may be necessary, but the nurse should begin by acknowledging the client's feelings. Fear is not necessarily indicative of ineffective coping.

A client has just returned to the postsurgical unit from postanesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this client's immediate plan of care?

Acute pain related to tissue manipulation and incision Although many clients experience minimal pain, it is still important to assess for this postsurgical complication. Sorrow and ineffective coping are possible, but neither is likely to be evident in the immediate postoperative period. There is minimal risk of trauma.

A client has been discharged home after a total mastectomy without reconstruction. The client lives alone and has a home health referral. When the home care nurse performs the first scheduled visit on this client, what should the nurse assess? Select all that apply.

Adherence to the exercise plan Overall psychological functioning Integrity of surgical drains Clients who have difficulty managing their postoperative care at home may benefit from a home health care referral. The home care nurse assesses the client's incision and surgical drain(s), adequacy of pain management, adherence to the exercise plan, and overall physical and psychological functioning. It is unnecessary to assess the client's understanding of cancer at this stage of recovery. Prostheses may be considered later in the recovery process.

A nurse is reviewing a female client's history, which includes the following information:Age at menarche: 14 yearsCesarean delivery: 2 pregnanciesAge at first pregnancy: 35 yearsAlcohol use: approximately 1 to 2 glasses of wine/monthThe nurse identifies which as a possible risk factor for the client to develop breast cancer?

Age at first pregnancy Risk factors for breast cancer include an early menarche (before 12 years), nulliparity, late age at first full-term pregnancy, and an alcohol intake of 2 to 5 drinks daily.

A client in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The client shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well overall to her diagnosis and surgery. What nursing intervention is most appropriate to support this client's coping?

Arrange a referral to a community-based support program. The client is not exhibiting clear signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences. The nurse may educate the client's spouse or partner to listen for concerns, but the nurse should not tell the client's spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She cannot be expected to be optimistic at all times.

A client returns to the recovery room following a mastectomy. An initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

Assessing the vital signs and oxygen saturation levels. The nurse prioritizes vital signs and breathing based on principles of ABCs.

The nurse is caring for a client who has just had a radical mastectomy and axillary node dissection. When providing client education regarding rehabilitation, what should the nurse recommend?

Avoid lifting objects heavier than 10 pounds (4.5 kg). Following an axillary dissection, the client should avoid lifting objects greater than 5 to 10 pounds, cutting the cuticles, and undergoing venipuncture on the affected side. Exercises of the hand and arm are encouraged and the use of a sling is not necessary.

A client has just been told she needs to have an incisional biopsy of a right breast mass. During preoperative teaching, how could the nurse best assess this client for specific educational, physical, or psychosocial needs she might have?

By encouraging her to verbalize her questions and concerns During the preoperative visit, the nurse assesses the client for any specific educational, physical, or psychosocial needs that she may have. This can be accomplished by encouraging her to verbalize her fears, concerns, and questions. Reviewing her medical history may be beneficial, but it is not the best way to ascertain her needs. Discussing possible findings of the biopsy and possible treatment options is the responsibility of the treating physician.

The nurse working on a cancer treatment floor assesses her assigned clients. It is most important for the nurse to report which assessment finding?

Coolness and mottling of a newly constructed breast site Mottling or an obvious decrease in skin temperature may signify flap loss and needs to be reported to the surgeon immediately. The vital signs presented are within acceptable range for a postoperative client. Throat discomfort immediately following surgery is an expected effect of airway management during surgery. A small amount of bloody drainage is an expected finding 12 hours postoperatively.

A woman calls the clinic and tells the nurse she has had bloody drainage from her right nipple. The nurse makes an appointment for this client, expecting the physician or practitioner to order what diagnostic test on this client?

Galactography Galactography is a diagnostic procedure that involves injection of less than 1 mL of radiopaque material through a cannula inserted into the ductal opening on the areola, which is followed by mammography. It is performed to evaluate an abnormality within the duct when the client has bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography. X-ray, PET, and ultrasound are not typically used for this purpose.

A patient is told that she has a common form of breast cancer where the tumor arises from the duct system and invades the surrounding tissues, often forming a solid irregular mass. What type of cancer does the nurse prepare to discuss with the patient?

Infiltrating ductal carcinoma Infiltrating ductal carcinoma—the most common histologic type of breast cancer accounts for 80% of all cases. The tumors arise from the duct system and invade the surrounding tissues. They often form a solid irregular mass in the breast.

The nurse is assessing an older adult female who has not seen her physician in 2 years. The nurse is assisting the patient into a gown and notices that the patient has edema and pitting of the skin on the right breast. What does the nurse understand is the significance of this finding?

It may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance, a classic sign of advanced breast cancer. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange peel appearance (peau d'orange)—a classic sign of advanced breast cancer.

Sentinel lymph node mapping is done to validate the lack of lymph node metastasis. Which complication does this technique help avoid?

Lymphedema Validating the lack of lymph node metastasis allows the surgeon to preserve more breast and axillary tissue and chest muscle. Leaving more normal lymph nodes intact reduces the potential for complications, such as lymphedema caused by the extensive disruption of lymphatic circulation.

A nurse is explaining that each breast contains 12 to 20 cone-shaped lobes. The nurse should explain that each lobe consists of what elements?

Lobules and ducts Each breast contains 12 to 20 cone-shaped lobes, which are made up of glandular elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together. These breast lobes do not consist of tendons, ligaments, endocrine glands, or smooth muscle.

A 60-year-old man presents at the clinic complaining that his breasts are tender and enlarging. The patient is subsequently diagnosed with gynecomastia. The patient should be assessed for the possibility of what causative factor?

Medication adverse effects Gynecomastia can also occur in older men and usually presents as a firm, tender mass underneath the areola. In these patients, gynecomastia may be diffuse and related to the use of certain medications. It is unrelated to fluid overload or nutrition and is not considered an age-related change.

The nurse recognizes which statement as accurately reflecting a risk factor for breast cancer?

Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) have had breast cancer. Increased risk is associated with early menarche (i.e. menses beginning before 12 years of age). Nulliparity and later maternal age at first birth are associated with increased risk for breast cancer. Alcohol use remains controversial; however, a slightly increased risk is found in women who consume even one drink daily and doubles among women drinking three drinks daily.

Which is inconsistent as a risk factor for breast cancer?

Multiparity Nulliparity is a risk factor for breast cancer, along with late menopause, older age, and family history of breast cancer, among others.

A patient has undergone surgery for breast cancer and the findings of the surgery are as follows:Invasive undifferentiated tumorSize 2.2 cmAxillary lymph nodes negativeHigh ERBB2 expressionWhich of these findings would suggest a favorable prognosis?

Negative lymph nodes The finding suggesting a favorable prognosis would be negative axillary lymph nodes. Other favorable factors would include noninvasive tumors or invasive tumors less than 1 cm in size, well-differentiated tumors, and low ERBB2 expression.

A nurse has assessed that a client is not yet willing to view her mastectomy site. How should the nurse best assist the client in developing a positive body image?

Provide the client with encouragement in an empathic and thoughtful manner. Gentle encouragement can help the client progress toward accepting the change in her appearance. The nurse should not downplay the significance of physical appearance. Explaining that others have had similar experiences may or may not benefit the client. Asking the client to describe the appearance of her breast is likely to exacerbate the woman's reluctance to do so.

A nurse is assisting with obtaining a specimen of breast milk from a mother with suspected mastitis. What organism would the nurse most expect to be found in the milk that would be consistent with a diagnosis of mastitis?

Staphylococcus aureus If a breast infection develops, the most common causative microorganism is Staphylococcus aureus, which often is resistant to antibiotic therapy. The other options are distracters for this question.

When planning discharge teaching with a client who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the client that she should report what sign or symptom to the health care provider immediately?

Sudden cessation of output from the drainage device The client should report sudden cessation of output from the drainage device, which could indicate an occlusion. Gradual decline in output is expected. A temperature of 38°C (100.4°F) or greater should also be reported to rule out postoperative infection, but a temperature of 36.9°C (98.5°F) is not problematic. Fatigue is expected during the recovery period.

A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis?

Tamoxifen Deep vein thrombosis, pulmonary embolism, and superficial phlebitis are all thromboembolic events that are adverse reactions to tamoxifen.

A nurse is examining a client who has been diagnosed with a fibroadenoma. The nurse should recognize what implication of this client's diagnosis?

The client might be referred for a biopsy. Fibroadenomas are firm, round, movable, benign tumors. These masses are nontender and are sometimes removed for biopsy and definitive diagnosis. They are not considered to be an age-related change, even though they are benign. Radiation therapy is unnecessary and fibroadenomas do not result from oral contraceptive use.

A nurse is obtaining health histories from clients at a busy low-income clinic. Which clients should the nurse follow more closely as being at the highest risk for developing breast cancer? Select all that apply.

The client who has relatives with the BRCA1 mutated gene The client with a mother who had breast cancer There are several risk factors that the nurse must identify; however, the most important risk factor to be identified is the presence of the mutated BRCA1 gene, which makes the client "very likely" to develop breast cancer. Breast cancer family history is another significant risk factor. Other risk factors include being female and being older than 50 years, but these clients are not at as high a risk for the development of breast cancer. Males are not a high-risk group. White women are at a higher risk than African Americans.

What is the most common location for breast cancer?

Upper outer quadrant of the breast Most breast cancers are found in the upper outer quadrant of the breast, where most breast tissues are located.

A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor?

Women's knowledge of how their breasts normally look and feel Current practice emphasizes the importance of breast self-awareness, which is a woman's attentiveness to the normal appearance and feel of her breasts. BSE does not need to be synchronized with the performance of mammograms. Rapport between the client and the care provider is beneficial, but does not necessarily determine the effectiveness of BSE. The woman does not need to understand the pathophysiology of breast cancer to perform BSE effectively.

A client is concerned about the lumps that have developed in her breasts and is fearful of cancer. The client reports variability in the size of the lumps. What could be causing this condition?

cyclical hormonal changes The likely cause is fibrocystic disease, which results from hormonal changes during the menstrual cycle.

A nurse is reviewing the organs most commonly affected by metastatic breast cancer. Which will not be included in this review?

kidneys The kidneys are not a common area of metastasis in patients with breast cancer. Lymph nodes most commonly are involved in metastasis, and the skeletal and pulmonary systems may also be involved (in that order). In addition, metastases may be found in the brain, adrenals, and liver.

A school nurse at a middle school finds that students are typically surprised to hear the role of women's breasts. What is their primary function?

lactation The breasts' primary function is the production of milk, a process referred to as lactation.

A client is very concerned about possibly having breast cancer, especially after caring for a close family member who recently died from the disease. The nurse informs the client that the primary and most common sign of breast cancer is a:

painless mass in the breast, most often in the upper outer quadrant. The primary sign of breast cancer is a painless mass in the breast, most often in the upper outer quadrant.