Reproductive--Lippincott Breast Cancer

21. A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's first course of action is to: 1. Do a breast examination and report the results to the physician. 2. Explain that pain is caused by hormonal fluctuations. 3. Reassure the client that pain is not a symptom of breast cancer. 4. Teach the client the correct procedure for breast self-examination (BSE).

21. 1. This information warrants the nurse's performing an examination and reporting the results to the physician. Hormone fluctuations do cause breast discomfort, but an examination must be done at this time to assess the breast. Although pain is not common with breast cancer, it can be a symptom. Teaching the client to perform a breast exam is important, but it is not the priority action in this case.

22. The nurse teaches a female client that the best time in the menstrual cycle to examine the breasts is during the: 1. Week that ovulation occurs. 2. Week that menstruation occurs. 3. First week after menstruation. 4. Week before menstruation occurs.

22. 3 . It is generally recommended that the breasts be examined during the first week after menstruation. During this time, the breasts are least likely to be tender or swollen because estrogen is at its lowest level. Therefore, the examination will be more comfortable for the client. The examination may also be more accurate because the client is more likely to notice an actual change in her breast that is not simply related to hormonal changes.

23. A female with bilateral breast implants asks if she still needs to do breast examinations because she does not know what to feel for. Which of the following is the nurse's best response? 1. "Have your partner assess your breasts on a regular basis." 2. "I will show you the correct technique as I do the breast examination." 3. "A breast examination is very difficult when you have had implant surgery." 4. "You need to have a mammogram instead."

23. 2. The client needs to become more confident and knowledgeable about the normal feel of the implants and her breast tissue. The best technique is for the nurse to demonstrate breast self-examination (BSE) to the client as the nurse conducts the clinical breast examination. Implant surgery does not exclude the need for monthly BSE. A mammogram is not a substitute for monthly BSE.

24. The client states that she has noticed that her bra fits more snugly at certain times of the month. She asks the nurse if this is a sign of breast disease. The nurse should base the reply to this client on the knowledge that: 1. Benign cysts tend to cause the breasts to vary in size. 2. It is normal for the breasts to increase in size before menstruation begins. 3. A change in breast size warrants further investigation. 4. Differences in breast size are related to nor mal growth and development.

24. 2. The breasts may vary in size before menstruation because of breast engorgement caused by hormonal changes. A woman may then note that her bra fits more tightly than usual. Benign cysts do not cause variation in breast size. A change in breast size that does not follow hormonal changes could warrant further assessment. The breasts normally are about the same size, although some women have one breast slightly larger than the other.

25. A 76-year-old client tells the nurse that she has lived long and does not need mammograms. Which is the nurse's best response? 1. "Having a mammogram when you are older is less painful." 2. "The incidence of breast cancer increases with age." 3. "We need to consider your family history of breast cancer first." 4. "It will be sufficient if you perform breast examinations monthly."

25. 2. Advancing age in postmenopausal women has been identified as a risk factor for breast cancer. A 76-year-old client needs monthly breast self- examination and a yearly clinical breast examination and mammogram to comply with the screening schedule. While mammograms are less painful as breast tissue becomes softer, the nurse should advise the woman to have the mammogram. Family history is important, but only about 5% of breast cancers are genetic.

26. After the surgeon met with a client to obtain the client's informed consent for a modified radical mastectomy, the client asks the nurse many questions about breast reconstruction that the nurse cannot to answer. The nurse should: 1. Inform the surgeon that the client has questions about reconstruction before she signs the consent. 2. Inform the client that she should concentrate on recovering from the mastectomy first. 3. Inform the client that she can have a consultation with the plastic surgeon in a few weeks. 4. Inform the client she can ask the surgeon these questions later when the surgeon makes rounds.

26. 1. If a client has questions the nurse cannot answer, it is best to delay the signing of the consent until the questions are clarified for the client. The surgeon should be notified, and the appropriate information or collaboration should be provided for the client before she signs the surgical consent. Telling her she should concentrate on recovery first ignores the client's questions and concerns. Frequently the plastic surgeon needs to be consulted at the beginning of the treatment because various surgical decisions depend on the future plans for breast reconstruction.

27. Prior to surgery for a modified radical mastectomy, the client is extremely anxious and asks many questions. Which of the following approaches would offer the best guide for the nurse to answer these questions. 1. Tell the client as much as she wants to know and is able to understand. 2. Delay discussing the client's questions with her until she is convalescing. 3. Delay discussing the client's questions with her until her apprehension subsides. 4. Explain to the client that she should discuss her questions first with the physician.

27. 1. An important nursing responsibility is preoperative teaching, and the most frequently recommended guide for teaching is to tell the client as much as she wants to know and is able to understand. Delaying discussion of issues about which the client has concerns is likely to aggravate the situation and cause the client to feel distrust. As a general guide, the client would not ask the question if she were not ready to discuss her situation. The nurse is available to answer the client's questions and concerns and should not delay discussing these with the client.

28. Atropine sulfate is included in the preoperative prescriptions for a client undergoing a modified radical mastectomy. The expected outcome is to: 1. promote general muscular relaxation. 2. decrease pulse and respiratory rates. 3. decrease nausea. 4. inhibit oral and respiratory secretions.

28. 4. Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.

29. During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. The best response by the nurse is which of the following? 1. "Cancer is not a punishment; it is a disease." 2. "You might feel better if you confided in your husband." 3. "Tell me more about your feelings about this." 4. "I can have the social worker talk to you if you would like."

29. 3. The nurse should respond with an open- ended statement that elicits further exploration of the client's feelings. Women with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict the client's feelings of punishment or offer advice such as confiding in the husband. A social worker referral may be beneficial in the future, but is not the first response needed to elicit exploration of the client's feelings.

30. Following a modified radical mastectomy, a client has an incisional drainage tube attached to Hemovac suction. The nurse determines the suction is effective when: 1. The intrathoracic pressure is decreased, and the client breathes easier. 2. There is an increased collateral lymphatic flow toward the operative area. 3. Accumulated serum and blood in the operative area are removed. 4. No adhesions are formed between the skin and chest wall in the operative area.

30. 3. A drainage tube is placed in the wound after a modified radical mastectomy to help remove accumulated blood and fluid in the area. Removal of the drainage fluids assists in wound healing and is intended to decrease the incidence of hematoma, abscess formation, and infection. Drainage tubes placed in a wound do not decrease intrathoracic pressure, increase collateral lymphatic flow, or prevent adhesion formation.

31. Which of the following positions would be best for a client's right arm when she returns to her room after a right modified radical mastectomy with multiple lymph node excisions? 1. Across her chest wall. 2. At her side at the same level as her body. 3. In the position that affords her the greatest comfort without placing pressure on the incision. 4. On pillows, with her hand higher than her elbow and her elbow higher than her shoulder.

31. 4. Lymph nodes can be removed from the axillary area when a modified radical mastectomy is done, and each of the nodes is biopsied. To facilitate drainage from the arm on the affected side, the client's arm should be elevated on pillows with her hand higher than her elbow and her elbow higher than her shoulder. A sentinel node biopsy procedure is associated with a decreased risk of lymphedema because fewer nodes are excised.

32. A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply. 1. Do not allow blood pressures or blood draws in the affected arm. 2. Avoid application of sunscreen on the left arm. 3. Use an electric razor for shaving. 4. Immobilize the left arm. 5. Elevate the left arm. 6. Perform hand pump exercises.

32. 1, 3, 5, 6. Blood pressures or blood draws in the affected arm, sun exposure, trauma with a sharp razor, and immobilization increase the risk of lymphedema. Elevation of the arm and hand pump exercises promote lymph flow and reduce edema.

33. The client with breast cancer is prescribed tamoxifen (Nolvadex) 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. The nurse's best response is which of the following? 1. "This drug is part of your chemotherapy program." 2. "This drug has been found to decrease metastatic breast cancer." 3. "This drug will act as an estrogen in your breast tissue." 4. "This drug will prevent hot flashes since you cannot take hormone replacement."

33. 2. Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.

34. A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about breast prosthesis and wigs. After answering the questions directly, the nurse should also: 1. Provide a list of resources, including the local breast cancer support group. 2. Offer a referral to the social worker. 3. Call the home health care agency. 4. Contact the plastic surgeon.

34. 1. Giving the client a list of community resources that could provide support and guidance assists the client to maintain her self-image and independence. The support group will include other women who have undergone similar therapies and can offer suggestions for breast products and wigs. Because the client is asking about specific resources, she does not need a referral to a social worker, home health agency, or plastic surgeon.

35. A client is to have radiation therapy after a modified radical mastectomy. The nurse should teach the client to care for the skin at the site of therapy by: 1. Washing the area with water. 2. Exposing the area to dry heat. 3. Applying an ointment to the area. 4. Using talcum powder on the area.

35. 1. A client receiving radiation therapy should avoid lotions, ointments, and anything that may cause irritation to the skin, such as exposure to sunlight, heat, or talcum powder. The area may safely be washed with water if it is done gently and if care is taken not to injure the skin.

36. The nurse should teach a client that a normal local tissue response to radiation following surgery for breast cancer is: 1. Atrophy of the skin. 2. Scattered pustule formation. 3. Redness of the surface tissue. 4. Sloughing of two layers of skin.

36. 3. The most common reaction of the skin to radiation therapy is redness of the surface tissues. Dryness, tanning, and capillary dilation are also common. Atrophy of the skin, pustules, and sloughing of two layers would not be expected and should be reported to the radiologist.

37. The nurse refers a client who had a mastectomy to "Reach to Recovery." The primary purpose of the American Cancer Society's Reach to Recovery program is to: 1. Foster rehabilitation in women who have had mastectomies. 2. Raise funds to support early breast cancer detection programs. 3. Provide free dressings for women who have had radical mastectomies. 4. Collect statistics for research from women who have had mastectomies.

37. 1. The American Cancer Society's Reach to Recovery is a rehabilitation program for women who have had breast surgery. It is designed to meet their physical, psychological, and emotional needs. The Reach to Recovery program is implemented by women who have had breast cancer themselves. Many women benefit from this peer information and support.