Nokea
After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)
- A. Peau d'orange
- B. Dense breast tissue
- C. Nipple retraction
- D. Mobile mass at two o'clock
- E. Non-tender axillary nodes
Correct Answer: A,C,D
Rationale: Peau d'orange (skin dimpling), nipple retraction, and a mobile mass at a specific location (e.g., two o'clock) are abnormal findings suggestive of breast cancer. Dense breast tissue and non-tender axillary nodes are not necessarily indicative of malignancy.
You may also like to solve these questions
A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug?
- A. It blocks the release of luteinizing hormone.
- B. It interferes with cancer cell division.
- C. It blocks estrogen in the breast.
- D. It inhibits DNA synthesis in rapidly dividing cells.
Correct Answer: C
Rationale: Tamoxifen (Nolvadex) reduces the estrogen available to breast tumors to stop or prevent growth. It does not block luteinizing hormone (leuprolide does this), interfere with cell division (chemotherapy agents like cyclophosphamide do this), or inhibit DNA synthesis (doxorubicin does this).
A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed?
- A. I can empty the drainage tubes daily and record the output.
- B. I should avoid lifting heavy objects with the affected arm.
- C. I can resume normal activities like swimming immediately.
- D. I will report any signs of infection, such as redness or swelling, to my provider.
Correct Answer: C
Rationale: The client should avoid strenuous activities like swimming until cleared by the provider to prevent complications such as lymphedema or infection. Emptying drainage tubes, avoiding heavy lifting, and reporting signs of infection are appropriate actions, indicating understanding.
The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.)
- A. Age greater than 65 years
- B. The elevated risk potential
- C. Osteoporosis
- D. Multiparity
- E. Genetic factors
Correct Answer: A,B,E
Rationale: Breast cancer risk factors include age greater than 65 (risk increases until age 80), increased breast density (elevated risk potential due to more glandular and connective tissue), and inherited mutations of BRCA1/BRCA2 genes. Osteoporosis and multiparity are not risk factors; high postmenopausal bone density and multiparity are moderate and low risk factors, respectively.
A woman diagnosed with breast cancer had these laboratory tests performed at an office visit. Which test results indicate to the nurse that some further diagnoses are needed?
- A. The elevated alkaline phosphatase and calcium suggest bone involvement.
- B. Only alkaline phosphatase is decreased, suggesting liver metastasis.
- C. Hematocrit and hemoglobin are decreased, indicating anemia.
- D. The elevated hematocrit and hemoglobin indicate dehydration.
Correct Answer: A
Rationale: The alkaline phosphatase (normal 30 to 120 U/L) and total calcium (normal 9 to 10.5 mg/dL) levels are elevated (125 U/L and 12 mg/dL, respectively), suggesting bone metastasis. Hematocrit (19%) and hemoglobin (14 g/dL) are within normal limits for females, ruling out anemia or dehydration.
The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding?
- A. This condition will become malignant over time.
- B. I should refrain from using hormone replacement therapy.
- C. One cup of coffee in the morning should be enough for time.
- D. This condition makes it more difficult to examine my breasts.
Correct Answer: A
Rationale: Fibrocystic breast condition does not increase a woman's chance of developing breast cancer. Hormone replacement therapy is not indicated since the additional estrogen may aggravate the condition. Limiting caffeine intake may give relief to tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps.