Nokea
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
- A. Evaluate the patients milk production.
- B. Palpate the area for a breast mass.
- C. Assess the patients knowledge of breast cancer.
- D. Assure the patient that this is likely an age-related change.
Correct Answer: B
Rationale: Dimpling of the breast is a concerning sign that may indicate an underlying breast mass or malignancy, such as breast cancer, due to possible lymphatic obstruction or tumor fixation. Palpating the area to assess for a mass is the most appropriate action to identify potential pathology and determine the need for referral. Evaluating milk production is irrelevant as there is no indication of lactation. Assessing knowledge is secondary to physical examination, and dimpling is not an age-related change.
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A patient has just returned to the postsurgical unit from post-anesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this patients immediate plan of care?
- A. Acute pain related to tissue manipulation and incision
- B. Ineffective coping related to surgery
- C. Risk for trauma related to post-surgical injury
- D. Chronic sorrow related to change in body image
Correct Answer: A
Rationale: Acute pain is a common immediate postoperative issue due to tissue manipulation and incision, making it a priority nursing diagnosis. Coping, sorrow, or trauma risks may emerge later but are not immediate concerns.
The nurse is teaching breast self-examination (BSE) to a group of women. The nurse should recommend that the patients perform BSE at what time?
- A. At the time of menses
- B. At any convenient time, regardless of cycles
- C. Weekly
- D. Between days 5 and 7 after menses
Correct Answer: D
Rationale: BSE is best performed on days 5 to 7 after menses, when breasts are least hormonal and tender, optimizing detection of abnormalities. Monthly, not weekly, performance is recommended, and timing relative to menses is important.
The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurses best response?
- A. Yes, its known to have a slight protective effect.
- B. Yes, but studies also show an increased risk of osteoporosis.
- C. You wont need to worry about getting cancer as long as you take Tamoxifen.
- D. Tamoxifen is known to be a highly effective protective measure.
Correct Answer: D
Rationale: Tamoxifen is a selective estrogen receptor modulator proven to significantly reduce the risk of breast cancer in high-risk women, making it a highly effective chemopreventive agent. It does not eliminate risk entirely, and it also helps prevent osteoporosis, not increase it. A slight protective effect understates its efficacy.
A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment?
- A. Lumpectomy and radiation
- B. Partial mastectomy and radiation
- C. Partial mastectomy and chemotherapy
- D. Total mastectomy and chemotherapy
Correct Answer: A
Rationale: A small, well-defined nodule suggests early-stage breast cancer, for which lumpectomy followed by radiation is a common treatment to preserve the breast while effectively treating the cancer. Mastectomy or chemotherapy may be considered for more advanced or aggressive disease, which is not indicated here.
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
- A. Nontenderness
- B. A size of 5 mm
- C. Softness and a regular shape
- D. Mobility
Correct Answer: A
Rationale: Malignant breast tumors are typically nontender, hard, fixed, and irregularly shaped. Small size, softness, or mobility are more characteristic of benign lesions like cysts.