Nokea
The nurse is caring for a patient with left arm lymphedema. Which of the following actions should be included in the plan of care?
- A. Check BP on both right and left arms.
- B. Avoid isometric exercise on the left arm.
- C. Assist with application of compression dressings.
- D. Keep the left arm at or below the level of the heart.
Correct Answer: C
Rationale: 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 right arm. The arm should not be placed in a dependent position.
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The nurse is conducting a breast assessment on a female patient. Which of the following findings is most indicative of a need for further evaluation?
- A. Bilateral nodules that are tender with palpation
- B. A nodule that is $1 \mathrm{cm}$ in size, painlessOf course! Here is a basic salad recipe with some ingredients and steps: painless
- C. and firm"
- D. A lump that increases in size before the menstrual period
- E. A lump that is small, mobile, and has a rubbery consistency
Correct Answer: B
Rationale: Painless and fixed lumps suggest breast cancer, a nodule that is $1 \mathrm{cm}$ in size, firm, and painless suggests breast cancer. The other findings are more suggestive of benign processes such as fibrocystic breasts and fibroadenoma.
A patient has a saline breast implant inserted in outpatient surgery. Which of the following instructions should the nurse include in the discharge teaching?
- A. Take Aspirin every 4 hours to reduce inflammation.
- B. Check wound drains for excessive blood or any foul odour.
- C. Wear a loose-fitting bra to decrease irritation of the sutures.
- D. Resume normal activities 2 to 3 days after the mammoplasty.
Correct Answer: B
Rationale: 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.
After a patient is diagnosed with lobular carcinoma in situ (LCIS), the nurse will anticipate that patient teaching may be needed about which of the following topics?
- A. Lumpectomy
- B. Lymphatic mapping
- C. Prilocaine
- D. Tamoxifen
Correct Answer: D
Rationale: 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.
The nurse is assessing a male patient and notes bilateral enlargement of the breasts. Which of the following actions should the nurse take first?
- A. Question the patient about any medications being currently used.
- B. Teach the patient about how to palpate the breast tissue for lumps.
- C. Refer the patient for mammography and biopsy of the breast tissue.
- D. Explain that this is a temporary condition due to hormonal changes.
Correct Answer: A
Rationale: The first action should be further assessment. Since gynecomastia is a possible adverse 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.
A student nurse prepares a list of teaching topics for a patient with a new diagnosis of breast cancer. Which of the following topics indicate that the student needs more education about breast cancer diagnostic testing?
- A. A firm, moveable mass is most often breast cancer
- B. HER-2 receptor testing
- C. Estrogen receptor testing
- D. Oncotype DX assay testing
Correct Answer: A
Rationale: A firm, moveable mass is characteristic of fibroadenoma, not breast cancer. The other tests are likely to be used for additional diagnostic testing in a patient with breast cancer.