Chapter 56: Breast Problems

A patient diagnosed with breast cancer asks the nurse what "triple negative" means. What would an accurate response from the nurse about triple-negative breast cancer include? a. The tumor is not likely to be responsive to hormone therapy. b. Treatment with chemotherapy is not likely to be recommended. c. HER-2 receptor testing was repeated for a total of three samples. d. Estrogen receptor testing identified three hormones causing the cancer.

A) A patient whose breast cancer tests negative for all 3 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.

The nurse is teaching a patient with a small immobile breast lump about options for a breast biopsy. Which type of biopsy would be scheduled in an operating room? a. Excisional biopsy b. Core needle aspiration c. Vacuum-assisted biopsy d. Fine-needle aspiration (FNA)

A) An excisional biopsy is done in an operating room. Core needle aspiration, vacuum-assisted biopsy, and fine-needle aspiration (FNA) are examples of minimally invasive breast biopsies.

Which topic would the nurse anticipate teaching a patient who is diagnosed with lobular carcinoma in situ (LCIS)? a. Lumpectomy b. Hormone therapy c. Lymphatic mapping d. MammaPrint testing

A) Hormone therapy may be used as a preventive measure to reduce breast cancer risk in some patients with LCIS. LCIS is a benign condition that is a risk factor for developing breast cancer, and no surgical or radiation treatment is indicated for LCIS.

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."

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.

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.

B) A compression sleeve 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.

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

B) 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.

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.

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 may increase in size and tenderness before menstruation. Nipple discharge associated with fibrocystic breasts is often milky, watery-milky, yellow, or green.

Which question is most pertinent for the nurse to ask a 43-yr-old patient about her risk for breast cancer? a. "Have you ever had a breast or chest injury?" b. "At what age did you start having menstrual periods?" c. "Is there a family history of fibrocystic breast changes?" d. "Do you often have back pain due to heavy breast tissue?"

B) Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Breast trauma and fibrocystic breast changes are not associated with increased breast cancer risk. Breast size or back pain caused by heavy breast tissue are not associated with increased breast cancer risk.

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 nonmobile c. A breast lump that increases in size before the menstrual period d. A breast lump that is small and mobile, with a rubbery consistency

B) Painless and nonmobile lumps suggest breast cancer. The other findings are more suggestive of benign processes such as fibrocystic breasts and fibroadenoma.

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.

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.

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

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.

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 needed. c. Visitors are restricted until the radiation therapy is completed. d. Wigs may be used until the hair regrows after radiation therapy.

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.

After a 48-yr-old patient has had a modified radical mastectomy, the pathology report identifies the tumor as an estrogen-receptor positive adenocarcinoma. Which medication would the nurse plan to explain to the patient? a. Estradiol b. Tamoxifen c. Raloxifene d. Trastuzumab

B) Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. 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.

The nurse notes bilateral enlargement of the breasts during examination of a 62-yr-old male patient. Which action would 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.

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.

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."

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.

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

C) Because HT is linked to an increased risk for breast cancer, the patient and health care provider must determine whether to use HT. 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.

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 reports fatigue. b. The patient eats only 25% of meals. c. The patient's apical pulse is irregular. d. The patient's white blood cell count is 5000/L.

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.

A 58-yr-old woman tells the nurse, "I understand that I have stage 2 breast cancer and I need to decide on a surgery, but I feel overwhelmed. What do you think I should do?" Which response would the nurse provide? a. "I would have a lumpectomy, but you need to decide what is best for you." b. "It would not be appropriate for me to make a decision about your health." c. "Tell me what you understand about the surgical options that are available." d. "There is no need to make

C) 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. 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.

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 death." d. "I can probably have reconstructive surgery at the same time as a mas

C) The overall survival rate with lumpectomy and radiation is the same as with mastectomy. The other patient statements indicate a good understanding of stage I breast cancer treatment.

Which nursing action would 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. Teach the patient to use the ordered patient-controlled analgesia every 10 minutes. b. Obtain a permanent breast prosthesis before the patient is discharged from the hospital. c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. d. Insist that the patient examine

C) The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the left 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.

The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph node dissection. Which action would the nurse take first? a. Explain the discharge care of the axillary drains. b. Teach the patient how to deep breathe and cough. c. Discuss options for postoperative pain management. d. Ask the patient to describe what she knows about the surgery.

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.

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/VN)? a. Teaching the patient how to avoid injury to the arm b. Assessing the patient's range of motion for the arm c. Evaluating the patient's understanding of drain care d. Giving an analgesic before scheduled arm exercises

D) LPN/VN 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.

When working in the women's health care clinic, which action would the nurse 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 34-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI).

D) MRI (in addition to mammography) is recommended for women who are at high risk for breast cancer, such as those with a BRCA-1 mutation. 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

Which information would the nurse include when teaching a young women's community service group about breast self-examination (BSE)? 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.

D) Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. Research has shown that BSE has no effect on reducing deaths from breast cancer. However, you still need to teach women the importance of knowing how their breasts look and feel and to report breast changes (e.g., nipple discharge, a lump) to their HCP. BSE would be done monthly. Annual mammograms are not routinely scheduled for women younger than age 40 years.

Which information at will the nurse provide to a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin)? 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.

D) Trastuzumab can lead to heart damage, so the patient is taught to self-monitor for symptoms of 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.