Chapter 51: Breast Disorders Lewis: Medical-Surgical Nursing, 10th Edition

The nurse teaching a young women's community service group about breast self-examination (BSE) will include that

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.

ANS: D

Performing BSE at the end of the menstrual period will reduce the breast tenderness

associated with the procedure. The evidence is not clear that BSE reduces mortality from

breast cancer. BSE should be done monthly. Annual mammograms are not routinely

scheduled for women younger than age 40 years, and newer guidelines suggest delaying them

until age 50.

DIF: Cognitive Level: Apply (application) REF: 1205

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

During a well-woman physical examination, a 43-yr-old patient asks about her risk for breast

cancer. Which question is most pertinent for the nurse to ask?

a. "Do you currently smoke tobacco?"

b. "Have you ever had a breast injury?"

c. "At what age did you start having menstrual periods?"

d. "Is there a family history of fibrocystic breast changes?"

ANS: C

Early menarche and late menopause are risk factors for breast cancer because of the prolonged

exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast

changes are not associated with increased breast cancer risk.

DIF: Cognitive Level: Apply (application) REF: 1209

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 51-yr-old patient with a small immobile breast lump is considering having a fine-needle

aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that

a. FNA is done in the outpatient clinic, and results are available in 1 to 2 days.

b. only a small incision is needed, resulting in minimal breast pain and scarring.

c. if the biopsy results are negative, no further diagnostic testing will be needed.

d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion.

ANS: A

FNA is done in outpatient settings, and results are available in 24 to 48 hours. No incision is

needed. FNA may be guided by ultrasound but not by mammogram. Because the immobility

of the breast lump suggests cancer, further testing will be done if the FNA results are

negative.

DIF: Cognitive Level: Apply (application) REF: 1206

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 fixed

c. A breast lump that increases in size before the menstrual period

d. A breast lump that is small, mobile, with a rubbery consistency

ANS: B

Painless and fixed lumps suggest breast cancer. The other findings are more suggestive of

benign processes such as fibrocystic breasts and fibroadenoma.

DIF: Cognitive Level: Apply (application) REF: 1212

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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 herbs are as effective as estrogen in relieving symptoms without increasing

the risk of breast cancer.

ANS: C

Because HT has been linked to increased risk for breast cancer, the patient and health care

provider must determine whether or not 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.

DIF: Cognitive Level: Apply (application) REF: 1217

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 58-yr-old woman tells the nurse, "I understand that I have stage II breast cancer and I need

to decide on a surgery, but I feel overwhelmed. What do you think I should do?" Which

response by the nurse is best?

a. "I would have a lumpectomy, but you need to decide what is best for you."

b. "Tell me what you understand about the surgical options that are available."

c. "It would not be appropriate for me to make a decision about your health."

d. "There is no need to make a decision rapidly; you have time to think about this."

ANS: B

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.

The nurse will teach a patient with metastatic breast cancer who has a new prescription for

trastuzumab (Herceptin) that

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.

ANS: D

Trastuzumab can lead to ventricular dysfunction, 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.

DIF: Cognitive Level: Apply (application) REF: 1218

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After a 48-yr-old patient has had a modified radical mastectomy, the pathology report

identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to

teach the patient about

a. tamoxifen c. raloxifene (Evista).

b. estradiol (Estrace). d. trastuzumab (Herceptin).

ANS: A

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.

DIF: Cognitive Level: Apply (application) REF: 1217

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which nursing action should 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. Obtain a permanent breast prosthesis before the patient is discharged from the hospital.

b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes.

c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm.

d. Insist that the patient examine the surgical incision when the initial dressings are removed.

ANS: 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.

DIF: Cognitive Level: Apply (application) REF: 1220

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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."

ANS: 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.

DIF: Cognitive Level: Apply (application) REF: 1215

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A 33-yr-old patient has a saline breast implant inserted in the outpatient surgery area. Which

instruction will the nurse include in the discharge teaching?

a. Take aspirin every 4 hours to reduce inflammation.

b. Check wound drains for excessive blood or a foul odor.

c. Wear a loose-fitting bra to decrease irritation of the sutures.

d. Resume normal activities 2 to 3 days after the mammoplasty.

ANS: B

The patient should be taught drain care because the drains will be in place for 2 or 3 days after

surgery. Normal activities can be resumed after 2 to 3 weeks. A bra that provides good

support is typically ordered. Aspirin will decrease coagulation and is typically not given after

surgery.

DIF: Cognitive Level: Apply (application) REF: 1219

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: 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.

DIF: Cognitive Level: Apply (application) REF: 1223

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 recurrence."

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

ANS: C

The survival rates with lumpectomy and radiation or modified radical mastectomy are

comparable. The other patient statements indicate a good understanding of stage I breast

cancer treatment.

DIF: Cognitive Level: Apply (application) REF: 1213

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information will the nurse include in patient teaching for a 36-yr-old patient who is

scheduled for stereotactic core biopsy of the breast?

a. A local anesthetic will be given before the biopsy specimen is obtained.

b. You will need to lie flat on your back and lie very still during the biopsy.

c. A thin needle will be inserted into the lump and aspirated to remove tissue.

d. You should not have anything to eat or drink for 6 hours before the procedure.

ANS: A

A local anesthetic is given before stereotactic biopsy. NPO status is not needed because no

sedative drugs are given. The patient is placed in the prone position. A biopsy gun is used to

obtain the specimens.

DIF: Cognitive Level: Apply (application) REF: 1206

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient diagnosed with breast cancer asks the nurse what "triple negative" means. An

accurate response from the nurse about triple-negative breast cancer should include that

a. the tumor is not likely to be responsive to hormone therapy.

b. HER-2 receptor testing was repeated for a total of three samples.

c. treatment with chemotherapy is not likely to be recommended.

d. estrogen receptor testing identified the three hormones causing the cancer.

ANS: A

A patient whose breast cancer tests negative for all three 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.

DIF: Cognitive Level: Apply (application) REF: 1211

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

The nurse will anticipate teaching a patient who is diagnosed with lobular carcinoma in situ (LCIS) about

a. tamoxifen.

b. lumpectomy.

c. lymphatic mapping.

d. MammaPrint testing.

ANS: A

Tamoxifen is used as a chemopreventive therapy in some patients with LCIS. The other

diagnostic tests and therapies are not needed because LCIS does not usually require treatment.

DIF: Cognitive Level: Apply (application) REF: 1217

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 necessary.

c. Visitors are restricted until the radiation therapy is completed.

d. Wigs may be used until the hair regrows after radiation therapy.

ANS: 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.

DIF: Cognitive Level: Apply (application) REF: 1216

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which patient statement indicates that the nurse's teaching about tamoxifen has been effective?

a. "I can expect to have leg cramps."

b. "I will call if I have any eye problems."

c. "I should contact you if I have hot flashes."

d. "I will be taking the medication for 6 to 12 months."

ANS: 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.

DIF: Cognitive Level: Apply (application) REF: 1217

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph

node dissection. Which action should the nurse take first?

a. Teach the patient how to deep breathe and cough.

b. Discuss options for postoperative pain management.

c. Explain the postdischarge care of the axillary drains.

d. Ask the patient to describe what she knows about the surgery.

ANS: 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.

DIF: Cognitive Level: Analyze (analysis) REF: 1218

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

When the nurse is working in the women's health care clinic, which action is appropriate to 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 28-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI).

ANS: D

MRI (in addition to mammography) is recommended for women who are at high risk for

breast cancer. 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.

DIF: Cognitive Level: Apply (application) REF: 1205

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

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.

ANS: B

Compression of the arm 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.

DIF: Cognitive Level: Apply (application) REF: 1220

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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.

ANS: 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 is usually

observed to increase in size and perhaps in tenderness before menstruation. Nipple discharge

associated with fibrocystic breasts is often milky, watery-milky, yellow, or green.

DIF: Cognitive Level: Apply (application) REF: 1206

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse notes bilateral enlargement of the breasts during examination of a 62-yr-old male

patient. Which action should 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.

ANS: 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.

DIF: Cognitive Level: Apply (application) REF: 1209

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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/LVN)?

a. Teaching the patient how to avoid injury to the left arm

b. Assessing the patient's range of motion for the left arm

c. Evaluating the patient's understanding of instructions about drain care

d. Administering an analgesic 30 minutes before scheduled arm exercises

ANS: D

LPN/LVN 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.

DIF: Cognitive Level: Apply (application) REF: 1220

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

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 complains of fatigue.

b. The patient eats only 25% of meals.

c. The patient's apical pulse is irregular.

d. The patient's white blood cell (WBC) count is 5000/μL.

ANS: 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.

DIF: Cognitive Level: Analyze (analysis) REF: 1217

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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."

ANS: 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.

DIF: Cognitive Level: Analyze (analysis) REF: 1218

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Psychosocial Integrity

The outpatient clinic receives telephone calls from four patients. Which patient should the nurse call back first?

a. A 57-yr-old patient with ductal ectasia who has sticky multicolored nipple discharge and severe nipple itching

b. A 21-yr-old patient with a family history of breast cancer who wants to discuss genetic testing for the BRCA gene

c. A 40-yr-old patient who still has left side chest and arm pain 2 months after a left modified radical mastectomy

d. A 50-yr-old patient with stage 2 breast cancer who is receiving doxorubicin and has ankle swelling and fatigue

ANS: D

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.

DIF: Cognitive Level: Analyze (analysis) REF: 1217

OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients

TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

ANS: A

The upper outer quadrant is the location of most of the glandular tissue of the breast.

DIF: Cognitive Level: Understand (comprehension) REF: 1212

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When using the accompanying illustration to teach a patient about breast self-examination, the

nurse will include the information that most breast cancers are located in which part of the

breast?

a. 1

b. 2

c. 3

d. 4

e. 5