Nokea
The nurse is completing the admission history for a client who is admitted for a reduction mammoplasty. Which of the following client statements is uncommon when explaining the rationale for the procedure?
- A. Back pain
- B. Low self-esteem
- C. Others disapprove
- D. Skin irritation
Correct Answer: C
Rationale: The rationale for a reduction mammoplasty most often comes from the client experiencing a complication due to the size of the breast. Back pain, low self-esteem, self-consciousness, and skin irritation are common rationales. The disapproval of others is not a common rationale.
You may also like to solve these questions
The nurse is caring for a client diagnosed with ductal carcinoma and lymph node involvement. Which diagnostic test, ordered by the physician, does the nurse identify as assessing possible metastasis?
- A. A complete blood count
- B. A chest x-ray
- C. A multiple gated acquisition (MUGA) scan
- D. A bone density test
Correct Answer: B
Rationale: A chest x-ray can identify any tumors present in the lung fields. Lymph nodes containing cancer cells are commonly involved in metastasis, which most frequently spreads to the skeletal and pulmonary systems (in that order). In addition, metastases may be found in the brain, adrenals, and liver. A blood count will not detect metastasis. A bone density study or MUGA scan will not detect metastasis.
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 obtaining a history from a client who states recurrent breast tenderness. The client inquiries if there is something wrong with her breasts. Which question by the nurse is a priority?
- A. Do you have a history of breast disorders and cancer in the family?
- B. Does the tenderness occur around the same time each month?
- C. Have you pulled a muscle or had any injury to the breast?
- D. When did you first recognize the symptoms?
Correct Answer: B
Rationale: The breasts are part of the female reproductive system, and they respond to the hormonal cycle associated with ovulation, menstruation, and pregnancy. Because the hormonal cycle is monthly, it is best to ask the client if the tenderness occurs at the same time each month. The other options are also important questions to ask.
The nurse is caring for a client whose physician has ordered a sentinel lymph node mapping. The physician explained the procedure and desired outcome. Which statement, made by the client, indicates a need for further instruction?
- A. The procedure allows for an understanding of the spread of cancer cells.
- B. The procedure allows for conservation of breast tissue.
- C. The procedure removes all cancer from the body.
- D. The procedure includes minimal surrounding tissue damage.
Correct Answer: C
Rationale: Sentinel lymph node mapping involves identifying the first (sentinel) lymph nodes through which the breast cancer cells would spread to regional lymph nodes in the axilla. Validating the lack of lymph node metastasis allows the surgeon to preserve more breast tissue, axillary tissue and chest muscle. Further instruction would be needed to explain that the sentinel lymph node biopsy does not remove cancer from the body.
A female client is diagnosed with breast abscess. She would like to continue to breast-feed her newborn. Which action by the nurse would be most appropriate in this situation?
- A. Encourage the client to include a client content in the diet.
- B. Instruct the client to wear a tight-fitting bra.
- C. Reduce the frequency of removing and reapplying the dressings.
- D. Assist the client to pump the breasts to remove breast milk.
Correct Answer: D
Rationale: The nurse should help the client pump the breasts and remove breast milk to prevent engorgement. Because the client has decided to continue breast-feeding, the client should wear a loose-fitting bra. Including protein content in the diet would be correlated to the client's current situation. Frequency of dressing changes does not play a role in the intervention.