Nokea
The nurse is caring for a client following breast reconstruction surgery using autogenous tissue. When assessing wounds from the surgical procedure, in which area would the nurse assess the wound from which tissue was taken?
- A. The vastus lateralis
- B. The rectus femoris
- C. Gluteus maximus
- D. Rectus abdominis
Correct Answer: D
Rationale: The area in which tissue is taken for breast reconstruction surgery is from the rectus abdominis muscle in a manner similar to a 'tummy tuck.' The nurse must assess this site for healing or complications.
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A client with a painless, firm, notender lump in the breast is being scheduled for diagnostic testing. Which test would the nurse expect the physician to order?
- A. Standard mammogram
- B. Ultrasound
- C. Excisional biopsy
- D. Culture of discharge
Correct Answer: B
Rationale: Ultrasound can reveal physical characteristics unique to a fibroadenom a versus malignant mass with a higher degree of accuracy than standard mammography. In the case of very young women - an atypical age for breast cancer - an excisional biopsy is performed only if the mass changes or becomes larger. If the mass is detected in a woman with a higher risk for developing breast cancer, such as one with a family history or of an older age, a biopsy is performed to confirm that the tissue is indeed benign. There is no discharge to culture.
The nurse is providing shift report related to a client newly received back to the unit from the post anesthesia care unit (PACU). The nurse is stating that the client had breast tissue removed with 7 of 14 lymph nodes, the lining of the chest muscles and pectoralis major and minor muscles removed. The oncoming nurse documents which procedure completed?
- A. A segmental mastectomy
- B. A total mastectomy
- C. A modified radical mastectomy
- D. A radical mastectomy
Correct Answer: D
Rationale: A modified radical mastectomy is a procedure in which the breast, some lymph nodes, the lining over the chest muscles, and the pectoralis minor muscle are removed. A segmental mastectomy is where the tumor and some breast tissue and lymph nodes are removed. A total mastectomy includes only breast tissue. A radical mastectomy removes the breast, axillary lymph nodes, and pectoralis major and minor muscles. Sternal lymph nodes may also be removed with this procedure.
During a follow-up visit, a female client who underwent a mastectomy presents with an infection that requires an antibiotic. The client reports having been doing some gardening. What further instruction and reinforcement of teaching should the nurse provide?
- A. Avoid working in the garden or yard altogether.
- B. Wear gloves and protective clothing to avoid any injuries.
- C. Increase the frequency of follow-up visits if she does work.
- D. Avoid household chores for at least 6 to 9 months.
Correct Answer: B
Rationale: The nurse should recommend that the client wear gloves when doing backyard work or housework to prevent injuries that may heal slowly or become infected. Working, whether it is in the backyard or doing some household chores, can be helpful in promoting feelings of usefulness, thereby increasing the client reporting abilities and self-state. The client should be advised to follow up more frequently, however, this would not help prevent any untoward injury.
The nurse is caring for a client with breast cancer and removal of axillary lymph nodes. Which assessment finding is documented and brought to the physician's attention as potential lymphedema?
- A. A reddened area around the breast
- B. Fluid accumulation under in the axilla
- C. Enlargement of the arm
- D. Pain in the chest wall
Correct Answer: C
Rationale: Enlargement of the arm is a key sign of lymphedema, which can occur after axillary lymph node removal due to impaired lymphatic drainage. A reddened area around the breast may indicate infection or inflammation, not lymphedema. Fluid accumulation under the axilla could be a seroma, not lymphedema. Pain in the chest wall is not specific to lymphedema.
A client complains of having tender and painful breasts, often feeling multiple jumps within the breast tissue. The nurse would need to gather additional information about which of the following?
- A. Alcohol and caffeine consumption
- B. Client's workplace in relation to the surroundings
- C. Timing of symptoms in relation to the menstrual cycle
- D. Bathing frequency and living surroundings
Correct Answer: C
Rationale: Considering that the client has tender and painful breasts and often feels lumps within her breast tissue, it is most likely that she suffers from fibrocystic breast disease. To confirm these findings, the nurse should ask relevant questions about the characteristics and timing of symptoms in relation to the menstrual cycle. Symptoms of fibrocystic breast disease are noticeable before menstruation and usually state during menstruation. The size of one cyst becomes larger before menstruation and often changes with the menstrual cycle. The nurse should further ask the client about her habits of smoking and consuming coffee, chocolate, and caffeinated soft drinks, not alcohol, because they aggravate the condition. Workplace surroundings or cleanliness habits do not matter because fibrocystic breast disease is not infectious.