Chapter 54 Clients with Breast Disorders

The nurse is caring for a client who is beginning doxorubicin (Adriamycin) therapy for breast cancer. When preparing the client for probable side effects, which would the nurse include? A) Information regarding wigs from the American Cancer Society B) Information about blood donation from the American Red Cross C) Information regarding high caloric meals from a dietician D) Information regarding depression from a mental health association

Ans: A Feedback: Alopecia is a common side effect from the use of doxorubicin (Adriamycin). It is best for the client to be proactive in planning for hair loss so that the client has a suitable plan. Also, the American Cancer Society in some areas offers financial support and guidance in obtaining a wig or head covering. Blood donation is not completed during chemotherapy because anemia is common. Due to recent antiemetic medications, nausea is less common not as prolonged. Client's rarely need a high-calorie diet. Emphasis is placed on nutrient dense, not calorie dense. Depression may be a concern, and a support group is an excellent resource. A mental health association may be more than what is needed.

The nurse is caring for a breastfeeding client who has developed a breast abscess. When instructing on the cause of abscess formation, which organism is the most common cause? A) Staphylococcus aureus B) Escherichia coli C) Pseudomonas aeruginosa D) Enterococcus faecalis

Ans: A Feedback: An abscess in the breast is most frequently a complication of mastitis. The most common cause is Staphylococcus aureus (S. aureus).

A client with breast cancer is scheduled to undergo chemotherapy with aromatase inhibitors. Which of the following best reflects the rationale for using this group of drugs? A) They lower the level of estrogen in the body blocking the tumor's ability to use it. B) They block progesterone-dependent tumors from growing. C) They attach to endogenous protein receptors to slow the growth of cancerous cells. D) They stimulate the immune system to attack a protein common in many tumors.

Ans: A Feedback: Aromatase inhibitors lower the level of estrogen in the body thereby interfering with the ability of hormone-sensitive tumors to use estrogen for growth. Antiprogestin drug, such as mifepristone, blocks progesterone-dependent breast cancers. The monoclonal antibody, trastuzumab attaches to protein receptors to slow the growth of cancer cells. A breast cancer vaccine is under investigation in Italy. This vaccine stimulates the immune system to attack a protein called mammaglobin-A, which is found in 80% of breast cancer tumors.

The nurse is caring for a client diagnosed with fibrocystic disease and prescribed danazol (Danocrine). Which is essential before drug therapy is initiated? A) Pregnancy test B) Liver function test C) MUGA scan D) Blood chemistry

Ans: A Feedback: Before initiating drug therapy, it is essential to confirm that the client is not pregnant. Ingesting danazol (Danocrine) may be teratogenic to the fetus. Liver function test, MUGA scan, and blood chemistry can provide relevant information of the status of the liver, heart, and general overall condition.

A nurse is describing the advantages and disadvantages associated with tamoxifen therapy as a means of breast cancer prevention. The nurse would identify that the drug has a beneficial effect on which of the following? A) Bone mineral density B) High density lipoprotein levels C) Risk for endometrial cancer D) Cataract formation

Ans: A Feedback: Besides reducing the risk of breast cancer, tamoxifen preserves bone mineral density, thus preventing osteoporosis. It also lowers the low-density lipoprotein cholesterol levels, although it is still unknown if it decreases the incidence of myocardial infarction in women. Tamoxifen can have detrimental effects. It increases the incidences of endometrial cancer, deep vein thrombosis, pulmonary embolism, and cataracts.

The nurse is caring for a client who is diagnosed with an estrogen-sensitive tumor and has undergone a mastectomy. When instructing the client on potential medications, which medication(s) are stressed? A) Tamoxifen (Nolvadex) and aromatase inhibitors (Femara) B) Paclitaxel (Taxol) and doxorubicin (Adriamycin) C) Mifepristone (RU486) D) Testolactone (Teslac)

Ans: A Feedback: Clinical trials suggest that clients with an estrogen-sensitive tumor may benefit from tamoxifen (Nolvadex) or an aromatase inhibitor such as letrozole (Femara) for 5 years or more following a mastectomy. These medications alone or in combinations are found to be effective for preventing breast cancer reoccurrence and metastatic disease.

The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which of the following? A) Lymphedema B) Fibrocystic breast disease C) Fibroadenoma D) Breast abscess

Ans: A Feedback: Lymphedema occurs in some women after breast cancer surgery. It causes disfigurement and increases the lifetime potential for infection and poor healing. Fibrocystic breast disease and fibroadenoma are two benign breast conditions that occur usually in premenopausal woman. Breast abscess is the infectious and inflammatory breast condition that is common among breastfeeding mothers.

The nurse is caring for a group of breast cancer survivors postmastectomy. When developing a list of instructions of points to avoid, which point is highlighted? A) No lifting greater than 15 lb B) Wearing loose fitting shirts C) Applying cream to breast D) Arm exercises on affected side

Ans: A Feedback: Of the list citing things to avoid, the correct option to avoid is lifting more than 15 lb. This fact is important and needs to be highlighted. Tight-fitting or constrictive clothing is to be avoided. The client is encouraged to place cream on any area of the breast which is dry. Arm exercises are routinely completed on the affected arm.

The nurse is caring for four clients in an oncology unit. Following report on diagnosis and treatment, which client would the nurse identify as having the most life-threatening diagnosis? A) A client with stage IV cancer receiving palliative care B) A client diagnosed with a stage one tumor with no lymph node involvement C) A client receiving chemotherapy and radiation with a low blood count D) A client with an estrogen receptor-positive tumor receiving oral chemotherapy

Ans: A Feedback: The client with stage IV cancer, indicating metastasis, and receiving palliative care, which includes comfort measures, is in highest life-threatening condition. A client with a stage I tumor and no lymph node involvement has a good prognosis as the cancer has been caught at an early stage. A low blood count is common when the client is receiving chemotherapy. It is common to have chemotherapy and radiation is a treatment regimen. Clients have experienced good prognosis with estrogen receptor positive tumor treatment of oral chemotherapy.

The nurse is caring for a client who has been diagnosed with a breast lump. The physician states that studies indicate a cancerous tumor in situ. The client is anxious and wants to know what may come next. The nurse is most correct to support physician instruction of which of the following? A) "Since your tumor appears localized, removal of the tumor is indicated." B) "A mastectomy is recommended for all clients in this situation." C) "The next step is just as the physician described. We can have the physician talk to you again." D) "Chemotherapy and radiation are typical treatments prescribed by the oncologist."

Ans: A Feedback: The nurse is correct to restate the information that the physician has just discussed. Many times, anxious clients have a difficult time understanding information. The nurse realizes that a tumor that is in situ has developed in a localized area without invading the surrounding tissue. This criterion would allow the removal of tissue from only that area, not an entire mastectomy. When the client asks for the next step, chemotherapy and radiation, as indicated, would be initiated after removal of the tumor.

5. A client is considering breast augmentation. Which of the following would the nurse recommend to the client to ensure that there are no malignancies? A) Mammogram B) Mastopexy C) Ultrasound D) Breast biopsy

Ans: A Feedback: When caring for a client considering breast augmentation, the nurse should provide her with a general guideline to have a mammogram to verify that there are no malignancies. Mastopexy involves a breast life for drooping breasts. Ultrasound or breast biopsy would not be necessary unless there was evidence of a problem.

The nurse is working at an oncologist's office specializing in breast cancer. The nurse cares for individuals of varied ages, backgrounds, and stages of breast cancer. Which criteria are considered a priority when determining adjunct treatment in addition to surgery? Select all that apply. A) Stage of tumor B) Cosmetic consequence C) Presence of metastasis D) Age E) Gender F) Sensitivity to estrogen

Ans: A, C, D, F Feedback: When working in an oncologists' office, the nurse is correct to identify that the stage of tumor and presence of metastasis help to guide treatment. Other factors include age of client and sensitivity to estrogen. Cosmetic consequence is not considered a priority when considering lifesaving treatment options. Many times, reconstruction is a possibility. Gender is not a consideration because treatment options are very similar.

The nurse is caring for a client diagnosed with ductal carcinoma and lymph node involvement. Which diagnostic test, ordered by the physician, does the nurse identify as assessing possible metastasis? A) A complete blood count B) A chest x-ray C) A multiple gated acquisition (MUGA) scan D) A bone density test

Ans: B Feedback: A chest x-ray can identify any tumors present in the lung fields. Lymph nodes containing cancers cells are commonly involved in metastasis, which most frequently spreads to the skeletal and pulmonary systems (in that order). In addition, metastases may be found in the brain, adrenals, and liver. A blood count will not detect metastasis. A bone density study or MUGA scan will not detect metastasis.

A client is scheduled to undergo a procedure to lift her breasts that have drooped because of significant weight loss. The nurse identifies this procedure as which of the following? A) Reduction mammoplasty B) Mastopexy C) Autogenous breast reconstruction D) Mastectomy

Ans: B Feedback: A mastopexy is a procedure that involves lifting a breast. This procedure is similar to a reduction mammoplasty (removal of glandular breast tissue, fat, and skin bilaterally to decrease the size of large pendulous breasts), although the incision and scar line are smaller and the recovery time is shorter. Autogenous breast reconstruction involves the harvesting of the client's tissue from the rectus abdominis muscle to create a new breast. A mastectomy is a removal of a breast.

The nursing is caring for a client who will be having artificial implants for breast reconstruction. The client is arriving at the physician's office for which procedure completed before the surgery can be done? A) Incisional alignment B) Tissue expansion C) Fluid drainage D) Pain control

Ans: B Feedback: Before an implant for breast reconstruction can produce an optimum cosmetic appearance, the skin and tissue on the chest wall are expanded to provide a large enough space to fill and approximate the size of the remaining breast. The other options are not correct.

The nurse is obtaining a history from a client who states recurrent breast tenderness. The client inquires if there is something wrong with her breasts. Which question by the nurse is best? A) "Do you have a history of breast disorders and cancer in the family?" B) "Does the tenderness occur around the same time each month?" C) "Have you pulled a muscle or had any injury to the breast?" D) "When did you first recognize the symptoms?"

Ans: B Feedback: The breasts are part of the female reproductive system, and they respond to the hormonal cycle associated with ovulation, menstruation, and pregnancy. Because the hormonal cycle is monthly, it is best to ask the client if the tenderness occurs at the same time each month. The other options are also important questions to ask.

The nurse at a gynecologist's office is obtaining a client history including the fact that several of the client's relatives have had breast cancer. Which general information regarding the most common type of cancer is accurate? A) Inflammatory breast cancer B) Ductal carcinoma C) Lobular carcinoma D) Medullary carcinoma

Ans: B Feedback: The nurse is most accurate to state that the most common malignancy is ductal carcinoma overwhelmingly at 80%. Inflammatory breast cancer is 1% to 3%, lobular carcinoma is 10%, and medullary carcinoma is rare.

During a follow-up visit, a female client who underwent a mastectomy presents with an infection that requires an antibiotic. She admits she has been doing some gardening. What further instruction and reinforcement of teaching is needed? A) Avoid working in the garden or yard altogether. B) Wear gloves and protective clothing to avoid any injuries. C) Increase the frequency of follow-up visits if she does works. D) Avoid household chores for at least 6 to 9 months.

Ans: B Feedback: The nurse should recommend that the client wear gloves when doing backyard work or housework to prevent injuries that may heal slowly or become infected. Working, whether it is in the backyard or doing some household chores, can be helpful in promoting feelings of usefulness, thereby, enhancing the client's coping abilities and self-esteem. She could be advised to follow up more frequently; however, this would not help prevent any untoward injury.

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. Which response by the nurse is most correct? A) An ultrasound B) A biopsy C) A magnetic resonance imaging (MRI) D) A clinical breast exam

Ans: B Feedback: To confirm whether a breast lump is cancerous or benign, a tissue sample must be obtained to examine the cells. Although an ultrasound, MRI, and clinical breast exam provides data on the characteristics of the lump, only examining the tissue can specifically identify if and what type of cancer is present.

A client with a fibroadenoma is being scheduled for diagnostic testing. Which of the following would the nurse expect as most likely? A) Mammogram B) Ultrasound C) Excisional biopsy D) Culture of discharge

Ans: B Feedback: Ultrasound can reveal physical characteristics unique to a fibroadenoma versus malignant mass with a higher degree of accuracy than mammography. In the case of very young women—an atypical age for breast cancer—an excisional biopsy is performed only if the mass changes or becomes larger. If the mass is detected in a woman with a higher risk for developing breast cancer, such as one with a family history or of an older age, a biopsy is performed to confirm that the tissue is indeed benign. There is no discharge to culture.

14. The nurse is providing dietary instruction for the client with fibrocystic breast disease. Which of the client's favorite foods are discouraged? (Select all that apply.) A) Lasagna B) Chocolate pudding C) Organ meat D) Cola products E) Popcorn

Ans: B, D Feedback: When instructing the client on appropriate food choices, the nurse instructs the client to avoid caffeine. Caffeine is in products such as chocolate and cola drinks.

The nurse is providing shift report related to a client newly received back to the unit from the postanesthesia care unit (PACU). The nurse is stating that the client had breast tissue removed with 7 of 14 lymph nodes, the lining of the chest muscles and pectoralis minor muscle removed. The oncoming nurse documents which procedure completed? A) A segmental mastectomy B) A total mastectomy C) A modified radical mastectomy D) A radical mastectomy

Ans: C Feedback: A modified radical mastectomy is a procedure in which the breast, some lymph nodes, the lining over the chest muscles, and the pectoralis minor muscle is removed. A segmental mastectomy is where the tumor and some breast tissue and lymph nodes are removed. A total mastectomy includes only breast tissue. A radical mastectomy includes the breast axillary lymph nodes, and pectoralis major and minor muscles are removed. Sternal lymph nodes may also be removed with this procedure.

The lactation nurse is caring for a mother who is 2 weeks postpartum and has mastitis. Which statement, made by the client, requires instruction and is the probable cause of the mastitis? A) "I feed the baby every 2 hours." B) "I break the baby's suck before pulling the baby off of the breast." C) "I nurse the baby on one breast each feeding." D) "I use a lanolin ointment on my dry nipples."

Ans: C Feedback: Because the client has mastitis, emptying each breast with alternate feedings is important. The baby's suck is strongest at the beginning of the feeding; thus, the mother should alternate the breast that the baby starts nursing from. If not, one breast would not be drained of the milk.

A client complains of having tender and painful breasts, often feeling multiple lumps within her breast tissue. The nurse would need to gather additional information about which of the following? A) Alcohol and caffeine consumption B) Client's workplace in relation to the surroundings C) Timing of symptoms in relation to the menstrual cycle D) Bathing frequency and living surroundings

Ans: C Feedback: Considering that the client has tender and painful breasts and that she often feels lumps within her breast tissue, it is most likely that she suffers from fibrocystic breast disease. To confirm these findings, the nurse should ask relevant questions about the characteristics and timing of symptoms in relation to the menstrual cycle. Symptoms of fibrocystic breast disease are noticeable before menstruation and usually abate during menstruation. The size of the cyst becomes larger before menstruation and often changes with the menstrual cycle. The nurse should further ask the client about her habits of smoking and consuming coffee, chocolate, and caffeinated soft drinks, not alcohol, because they aggravate the condition. Workplace surroundings or cleanliness habits do not matter because fibrocystic breast disease is not infectious.

A family member asks the nurse of the benefits of immunotherapy. The nurse would be most correct to state which of the following? A) Immunotherapy strengthens the immune system to prevent cancer. B) Immunotherapy uses homeopathic properties to prevent free radical release. C) Immunotherapy stimulates the immune response to attack and rid the body of cancer cells. D) Immunotherapy promotes removal of good and bad multiplying cells.

Ans: C Feedback: Immunotherapy is the basis for various drugs and therapeutic cancer vaccines. Rather than prevent breast cancer, they stimulate the immune system's ability to attack and rid the body of cancer cells. Immunotherapy does not prevent cancer, prevent free radical release, and remove good and bad multiplying cells.

When caring for a client experiencing metastatic cancer-related pain, which drug of choice is anticipated? A) Ibuprofen (Motrin) B) Alprazolam (Xanax) C) Morphine (MS Contin) D) Propofol (Diprivan)

Ans: C Feedback: In treating clients with metastatic cancer-related pain, the opioid analgesics morphine (MS Contin) and fentanyl are the drugs most often used for pain relief. Morphine (MS Contin) can be given orally, rectally, subcutaneously, intravenously, intramuscularly, or by epidural catheter. Ibuprofen (Motrin) is given for mild to moderate pain. Alprazolam (Xanax) is provided to relieve anxiety. Propofol (Diprivan) is an anesthetic given frequently for short procedures.

The nurse is caring for a client who is employed as a manual laborer and works with her hands. Which instruction would be most helpful? A) Do not return to work until all areas are completely healed. B) Have others assist in tasks involving use of affected arm. C) Wear gloves to prevent injury. D) Check to see if job description can be changed.

Ans: C Feedback: It is most helpful to provide an option that allows the client to continue with her job, if able. Many times, the client must continue employment and cannot change jobs. Instructing the client to not return to work may not be an option throughout the healing process, which could be up to 1 year. Asking others to do tasks and changing the job description are unrealistic throughout the recovery period.

The nurse is caring for a client with breast cancer and removal of axillary lymph nodes. Which assessment finding is documented and brought to the physician's attention as potential lymphedema? A) A reddened area around the breast B) Fluid accumulation under in the axilla C) Enlargement of the arm or hand D) Drainage from the areola

Ans: C Feedback: Lymphedema, soft-tissue swelling from accumulated lymphatic fluid, occurs in some women after they have undergone breast cancer surgery and the removal or irradiating of axillary lymph nodes. Lymphedema does not impact the breast area or axilla.

The nurse is caring for a client who is ordered a sentinel lymph node biopsy. The physician explained the procedure and desired outcome. Which statement, made by the client, indicates a need for further instruction? A) The procedure allows for an understanding of the spread of cancer cells. B) The procedure allows for conservation of breast tissue. C) The procedure removes all cancer from the body. D) The procedure includes minimal surrounding tissue damage.

Ans: C Feedback: Sentinel lymph node mapping involves identifying the first (sentinel) lymph nodes through which the breast cancer cells would spread to regional lymph nodes in the axilla. Validating the lack of lymph node metastasis allows the surgeon to preserve more breast tissue, axillary tissue and chest muscle. Further instruction would be needed to explain that the sentinel lymph node biopsy does not remove cancer from the body.

The nurse is completing the admission history for a client who is admitted for a reduction mammoplasty. Which of the following client statements is uncommon when explaining the rationale for the procedure? A) Back pain B) Low self-esteem C) Others disapprove D) Skin irritation

Ans: C Feedback: The rationale for a reduction mammoplasty most often comes from the client herself as she is experiencing a complication due to the size of the breast. Back pain, low self-esteem and a self-consciousness, and skin irritation are common rationales.

The client arrives at a public health clinic worried that she has breast cancer since finding a lump in her breast. When assessing the breast, which assessment finding is characteristic of fibrocystic disease? A) One breast is larger than the other. B) The lump is firm and nonmovable. C) The lump is round and movable. D) Nipple retractions are noted.

Ans: C Feedback: When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm, and nonmovable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

The nurse is caring for a client following breast reconstruction surgery using autogenous tissue. When assessing an wounds from the surgical procedure, in which area would the nurse assess the wound from which tissue was taken? A) The vastus lateralis B) The rectus femoris C) Gluteus maximus D) Rectus abdominis

Ans: D Feedback: The area in which tissue is taken for breast reconstruction surgery is from the rectus abdominis muscle in a manner similar to a "tummy tuck." The nurse must assess this site for healing or complications.

A female client is diagnosed with breast abscess. She would like to continue to breast-feed her newborn. Which of the following would be most appropriate in this situation? A) Encourage the client to include protein content in the diet. B) Instruct the client to wear a tight-fitting bra. C) Reduce the frequency of removing and reapplying the dressings. D) Assist the client to pump the breasts to remove breast milk.

Ans: D Feedback: The nurse should help the client pump the breasts and remove breast milk to prevent engorgement. Because the client has decided to continue breastfeeding, the client should wear a loose-fitting bra. Including protein content in the diet would be unrelated to the client's current situation. Frequency of dressing changes does not play a role in the intervention.

A client with fibrocystic breast disease has been receiving treatment with danazol (Danocrine) therapy for the past 6 months. In anticipation of the drug being discontinued, the nurse instructs the client to inform the healthcare provider about which of the following? A) Nausea or vomiting occurring beyond 9 days after discontinuing the drug B) Inability to sleep after discontinuing the drug C) Constipation occurring 90 days after discontinuing the drug D) Lack of return of regular menses within 90 days after discontinuing the drug

Ans: D Feedback: The nurse should tell the client to inform the healthcare provider if regular menses do not resume within 90 days after discontinuing the drug. Nausea, constipation, and sleep are not associated with danazol or its discontinuation.

The nurse is obtaining health histories from women at a busy low-income clinic. Which of the following clients should the nurse follow closely as being at high risk for developing breast cancer? A) The client who is over 50 years of age B) The client with a mother who had breast cancer C) The client who is African American D) The client has relatives with the BRCA1 mutated gene

Ans: D Feedback: 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 that makes the client "very likely" to develop breast cancer. Other risk factors include being female, being older than 50 years old, and having a family history of breast cancer. White women are at a higher risk than African Americans.