Breast Disorders 1. A woman at the health clinic tells the nurse that she does not do breast selfexamination (BSE) because it just seems too much of a bother. What is the best response by the nurse about BSE? a. BSE is the most common way that breast cancer is discovered. b. It reduces mortality from breast cancer in women under the age of 50 years. c. It is useful to help women learn how their breasts normally look and feel. d. BSE has little value in detecting cancer and is not recommended anymore. 3. When teaching a 24-year-old woman who wants to learn BSE, the nurse knows that it is important to do what? a. Provide time for a return demonstration. b. Emphasize the statistics related to breast cancer survival and mortality. c. Have the woman set a consistent monthly date for performing the examination. d. Inform the woman that professional examinations are not necessary unless she finds an abnormality. 4. Which diagnostic test is most accurate and advantageous in terms of time and expense in diagnosing breast cancer? a. Mammography b. Excisional biopsy c. Fine-needle aspiration d. Core (core needle) biopsy 6. While examining a patient’s breasts, the nurse notes multiple, bilateral mobile lumps. To assess the patient further, what is the most appropriate question by the nurse? a. “Do you have a high caffeine intake?” b. “When did you last have a mammogram?” c. “Is there a history of breast cancer in your mother or sisters?” d. “Do the size and tenderness of the lumps change with your menstrual cycle?” 7. A patient has fibrocystic changes in her breast. The nurse explains to the patient that this condition is significant because it a. often turns to cancer over time. b. can be controlled with hormone therapy. c. makes it more difficult to examine the breasts. d. will eventually cause atrophy of normal breast tissue. 10. Which patient has the highest risk of breast cancer? a. 60-year-old obese man b. 58-year-old woman with sedentary lifestyle c. 55-year-old woman with fibrocystic breast changes d. 65-year-old woman with a sister diagnosed with breast cancer 11. The nurse would be most concerned when the patient’s breast examination reveals which finding? a. A large, tender, moveable mass in the upper inner quadrant b. An immobile, hard, nontender lesion in the upper outer quadrant c. A 2- to 3-cm, firm, defined, mobile mass in the lower outer quadrant d. A painful, immobile mass with reddened skin in the upper outer quadrant 12. The best prognosis is indicated in the patient with breast cancer when diagnostic studies reveal a. negative axillary lymph nodes. b. aneuploid DNA tumor content. c. cells with high S-phase fractions. d. an estrogen receptor– and progesterone receptor–negative tumor. Axillary lymph node status is one of the most important prognostic factors in primary breast cancer; the more nodes involved, the higher the risk for relapse or metastasis. Aneuploid DNA tumor content shows that cells have abnormally high or low DNA content compared with normal cells and is associated with tumor aggressiveness. Cells in S-phase have a higher risk for recurrence and can produce earlier cancer death. Hormone receptor–negative tumors are usually poorly differentiated histologically, often recur, and are usually unresponsive to hormonal therapy. 13. The health care provider of a patient with a positive biopsy of a 2-cm breast tumor has recommended a lumpectomy with radiation therapy or a modified radical mastectomy as treatment. The patient says that she does not know how to choose and asks the female nurse what she would do if she had to make the choice. What is the best response by the nurse to this patient? a. “It doesn’t matter what I would do. It is a decision you have to make for yourself.” b. “There are advantages and disadvantages of both procedures. What do you know about these procedures?” c. “I would choose the modified radical mastectomy because it would ensure that the entire tumor was removed.” d. “The lumpectomy maintains a nearly normal breast, but the survival rate is not as good as it is with a mastectomy.” 14. A patient undergoing either a mastectomy or a lumpectomy for treatment of breast cancer can usually expect to undergo what other treatment? a. Chemotherapyg b. Radiation therapy c. Hormonal therapy d. Sentinel lymph node dissection (SLNB) Sentinel lymph node dissection (SLND) has become the standard of care, with axillary lymph node dissection reserved for patients with clinical indications of disease in the axilla. SLND provides prognostic information and helps determine further treatment. A lumpectomy, or breast-conservation surgery, is followed by radiation therapy to the entire breast and the use of chemotherapy or hormone therapy depends on the characteristics of the tumor and evidence of metastases. 15. SLNB is planned for a patient undergoing a modified radical mastectomy for breast cancer. What does the nurse teach the patient and her family about the purpose of this specific procedure? a. SLNB provides metastatic lymph nodes to test for responsiveness to chemotherapy. b. If cancer cells are found in any sentinel nodes, a complete axillary lymph node dissection will be done. c. If 1 sentinel lymph node is positive for malignant cells, all the sentinel lymph nodes will be removed. d. A radioisotope shows which lymph nodes are most likely to have metastasis, and all those nodes are removed. In a sentinel lymph node biopsy (SLNB) radioisotopes or dye identify lymph nodes that drain from the tumor site, and they are removed. Those nodes are examined for malignant cells. If any of the nodes have malignant cells, the next step is a complete axillary lymph node dissection (ALND). If the sentinel nodes are negative, no other lymph nodes are removed. 17. A patient with a positive breast biopsy tells the nurse that she read about tamoxifen on the Internet and asks about its use. The best response by the nurse includes which information? a. Tamoxifen is the treatment of choice if the tumor has receptors for estrogen on its cells. b. Tamoxifen is the primary treatment for breast cancer if axillary lymph nodes are positive for cancer. c. Tamoxifen is used only to prevent the development of new primary tumors in women with high risk for breast cancer. d. Because tamoxifen has been shown to increase the risk for uterine cancer, it is used only when other treatment has not been successful. 18. During the immediate postoperative period after a modified radical mastectomy, the nurse initially institutes which exercises for the affected arm? a. Have the patient brush or comb her hair with the affected arm. b. Perform full passive range-of-motion (ROM) exercises to the affected arm. c. Ask the patient to flex and extend the fingers and wrist of the operative side. d. Have the patient crawl her fingers up the wall, raising her arm above her head. As early as in the recovery room following a modified radical mastectomy, the patient should start flexing and extending the fingers and wrist of the affected arm with daily increases in activity. Postoperative mastectomy exercises, such as wall climbing with the fingers, shoulder rotation and extension, and hair care, are instituted gradually to prevent disruption of the wound. 19. Following a mastectomy, a patient develops lymphedema of the affected arm. What does the nurse teach the patient to do? a. Avoid skin-softening agents on the arm. b. Protect the arm from any type of trauma. c. Abduct and adduct the arm at the shoulder hourly. d. Keep the arm positioned so that it is in straight and dependent alignment. Removal of the axillary lymph nodes impairs lymph drainage from the affected arm and predisposes the patient to infection of the arm. The arm must be protected from even minor trauma. BP, venipunctures, and injections should not be done on the arm. The arm should never be dependent, even during sleep, and should be elevated to promote lymph drainage. 20. A patient who had a mastectomy and is undergoing radiation for treatment of breast cancer has a nursing diagnosis of disturbed body image. What is an appropriate nursing intervention for this patient? a. Provide the patient with information about surgical breast reconstruction. b. Restrict visitors and phone calls until the patient feels better about herself. c. Arrange for a Reach-to-Recovery visitor or similar resource available in the community. d. Encourage the patient to obtain a permanent breast prosthesis as soon as she is discharged from the hospital. The Reach-to-Recovery program consists of volunteers, all women, who have had breast cancer and can answer questions about what to expect at home, how to tell people about the surgery, and what prosthetic devices are available. It is a valuable resource for patients who have breast cancer and should be used if available in the community. If a volunteer is not available, the nurse is responsible for assisting the patient in the same manner. Although the nurse can discuss wearing a prosthesis, a permanent prosthesis cannot be used until healing is complete and inflammation is resolved. 22. A patient undergoing a modified radical mastectomy for cancer of the breast is going to use tissue expansion and an implant for breast reconstruction. What should the nurse teach the patient about tissue expansion? a. Injections of sterile saline into the expander will be needed over weeks to months. b. The expander cannot be placed until healing from the mastectomy is complete. c. This method of breast reconstruction uses the patient’s own tissue to replace breast tissue. d. The nipple from the affected breast will be saved to be grafted onto the reconstructed breast. When an expander is used to stretch the skin and muscle at the mastectomy site, the expander is gradually increased in size by weekly to monthly injections of sterile saline until the site is large enough for an implant to be inserted or stays in place to become the implant. Placement of the expander can be at the time of mastectomy or at a later date. An autologous tissue flap procedure is a type of reconstruction using the patient’s own tissue. The nipple of the affected breast is removed at mastectomy, and a new nipple can be reconstructed after breast reconstruction from various normal tissues. The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement? 1. Institute aspiration precautions. 2. Refer the client to Reach to Recovery. 3. Initiate seizure precautions. 4. Teach the client about mastectomy care. The client diagnosed with metastatic lesions to the brain is at high risk for seizures. The client frequently finds lumps in her breasts, especially around her menstrual period. Which information should the nurse teach the client regarding breast selfcare? 1. This is a benign process, which does not require follow-up. 2. The client should eliminate chocolate and caffeine from the diet. 3. The client should practice breast self- examination monthly. 4. This is the way breast cancer begins and the client needs surgery. 2. The client is diagnosed with breast cancer and is considering whether to have a lumpectomy or a more invasive procedure, a modified radical mastectomy. Which information should the nurse discuss with the client? 1. Ask if the client is afraid of having general anesthesia. 2. Determine how the client feels about radiation and chemotherapy. 3. Tell the client she will need reconstruction with either procedure. 4. Find out if the client has any history of breast cancer in her family. The client should understand the treatment regimen for follow-up care. A lumpectomy requires follow-up with radiation therapy to the breast and then systemic chemotherapy. If the cancer is in its early stages, this regimen has results equal to those with a modified radical mastectomy. 4. Which recommendation is the American Cancer Society’s (ACS) 2015 guideline for the early detection of breast cancer? 1. Beginning at age 18, have a biannual clinical breast examination by an HCP. 2. Beginning at age 30, perform monthly breast self-exams. 3. At age 45 through 54, receive a yearly mammogram. 4. Beginning at age 50, have a breast sonogram every five (5) years. 6. The nurse is teaching a class on breast health to a group of ladies at a senior citizen’s center. Which risk factor is the most important to emphasize to this group? 1. The clients should find out about their family history of breast cancer. 2. Men at this age can get breast cancer also and should be screened. 3. Monthly breast self-examination is the key to early detection. 4. The older a woman gets, the greater the chance of developing breast cancer. 7. The client who is scheduled to have a breast biopsy with sentinel node dissection states, “I don’t understand. What does a sentinel node biopsy do?” Which scientific rationale should the nurse use to base the response? 1. A dye is injected into the tumor and traced to determine spread of cells. 2. The surgeon removes the nodes that drain the diseased portion of the breast. 3. The nodes felt manually will be removed and sent to pathology. 4. A visual inspection of the lymph nodes will be made while the client is sleeping. A sentinel node biopsy is a procedure in which a radioactive dye is injected into the tumor and then traced by instrumentation and color to try to identify the exact lymph nodes the tumor could have shed into. 8. The client who is four (4) months pregnant finds a lump in her breast and the biopsy is positive for Stage II cancer of the breast. Which treatment should the nurse anticipate the HCP recommending to the client? 1. A lumpectomy to be performed after the baby is born. 2. A modified radical mastectomy. 3. Radiation therapy to the chest wall only. 4. Chemotherapy only until the baby is born. 9. The client who had a right modified radical mastectomy four (4) years before is being admitted for a cardiac work-up for chest pain. Which intervention is most important for the nurse to implement? 1. Determine when the client had chemotherapy last. 2. Ask the client if she received Adriamycin, an antineoplastic agent. 3. Post a message at the HOB for staff not to use the right arm for venipunctures or BPs. Examine the chest wall for cancer sites. The nurse should post a message at the head of the client’s bed to not use the right arm for blood pressures or laboratory draws. This client is at risk for lymphedema, and this is a lymphedema precaution. 11. The client who has had a mastectomy tells the nurse, “My husband will leave me now since I am not a whole woman anymore.” Which response by the nurse is most therapeutic? 1. “You’re afraid your husband will not find you sexually appealing?” 2. “Your husband should be grateful you will be able to live and be with him.” 3. “Maybe your husband would like to attend a support group for spouses.” 4. “You don’t know that is true. You need to give him a chance.” 12. The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make? 1. The hospital social worker. 2. CanSurmount. 3. Reach to Recovery. 4. I CanCope. The nurse is assessing a 34-year-old female client with fibrocystic breasts. Which question should the nurse ask the client during the assessment? 1. “Are your breasts more tender during your period?” 2. “Have you ever developed an allergy to chocolate?” 3. “Can you tell me more about your feelings of having fibrocystic breast changes?” 4. “Have you considered having a prophylactic mastectomy?” Mastalgia (breast pain and tenderness is common during the menstrual cycle. This question assists the nurse in determining if the mastalgia is from the fibrocystic disease. Which steps should the nurse provide clients who choose to perform breast selfexamination (BSE) according to the American Cancer Society (ACS) guidelines? Rank in order of performance. 1. Lie flat on the bed with a rolled towel placed under the scapula; perform palpation of each breast. 2. Pinch each nipple to see if fluid can be expressed. 3. With the breasts exposed, stand in front of a mirror and examine the breasts from front and each side. 4. In the shower, soap the breasts, and perform palpation in a systematic manner on each breast. 5. Find a private place where the self- examination can be performed. In order of performance: 5, 3, 4, 1, 2. 5. Breast self-examination should be performed in a private area with good lighting and a comfortable temperature so the woman is warm and can be consistent in the steps. 3. The first part of BSE is performed in front of a mirror. The breasts are examined from the front and each side, then with arms down by the side, then raised, next with the arms on the hips and bending over. The woman is looking for dimpling and irregularity in size or shape. 4. The woman then gets into a warm shower and palpates each breast when the breasts are soapy and slippery. 1. The last position the woman assumes is lying flat on the bed with a towel behind each scapula and palpation is performed. 2. After each breast is palpated the last thing done is to pinch the nipples to see if there is a discharge. 96. Which should the nurse teach the client regarding Breast Health Awareness (BHA) according to the American Cancer Society (ACS). Select all that apply. 1. Women at high risk should talk to the HCP about when to have a mammogram. 2. Beginning at age 45, to have a yearly mammogram. 3. To perform a breast self-examination (BSE) bimonthly. 4. To get a sonogram of the breasts semiannually. 5. To have Magnetic Rresonance Imaging of the breasts every five (5) years. 1. Women at high risk for breast cancer should have the opportunity to have mammograms beginning earlier than recommended for routine screening. 2. According to 2015 guidelines, routine screening mammograms should begin at age 45 and be performed yearly until age 55. At age 55 mammograms should be performed biennially. The nurse is performing the admission assessment on a 78-year-old female client and observes bilateral pendulous breasts with a stringy appearance. Which intervention should the nurse implement? 1. Request a mammogram. 2. Notify the HCP of the finding. 3. Continue with the examination. 4. Assess for peau d’orange skin. These are normal findings in the postmenopausal breast. Glandular tissue is replaced with fibrous tissue, the breasts become pendulous, and the Cooper’s ligaments become prominent. The client has a diagnosis of rule-out Paget’s disease. Which test provides a definitive diagnosis of the disease? 1. A breast biopsy. 2. A diagnostic mammogram. 3. Ultrasound of the breast. 4. Magnetic resonance imaging. Biopsy of the lesion is the only definitive test for Paget’s disease, a form of breast cancer accounting for about 1% of all breast cancers. The nurse is teaching a class on Breast Health Awareness. Which are the American Cancer Society’s recommended guidelines for the performance of breast selfexamination (BSE)? List in order of recommended performance. 1. Visualize the breast from the front while standing before a mirror. 2. Gently squeeze the nipple to express any fluid. 3. Turn to each side and view each breast in the mirror. 4. Palpate each breast in a circular motion while lying on the back. 5. Palpate each breast in a circular motion while in the shower. The order should be: 1, 3, 5, 4, 2. 1. The first step in BSE is to visualize the breasts for symmetry while looking at a frontal view before the mirror. 3. The next step is to turn from side to side, looking for any dimpling, puckering, or asymmetry, in front of a mirror. 5. The client should palpate the breasts in a warm shower with the breasts soaped to allow for the fingers to glide over the breast tissue. 4. After the shower, the client should lie on the bed with a towel rolled up and placed under the shoulder to flatten the breast tissue and palpate the breast. 2. The last step in BSE is to gently squeeze the nipple to determine if there is expressed fluid. The client is performing breast self-examination (BSE) by the American Cancer Society’s recommended steps and has completed palpating the breast. Which step is next when completing the BSE? 1. Stand before the mirror and examine the breast. 2. Lean forward and look for dimpling or retractions. 3. Examine the breast using a circular motion. 4. Pinch the nipple to see if any fluid can be expressed. 1. This step is the first step in BSE. 2. This is step three (3) in the BSE process. 3. This is included in steps four (4) and five (5) and is described as using a systematic process of examining the breast. Using circular motions and dividing the breast into wedges or vertical strips to palpate the entire breast is encouraged. This step was described in the stem as having been completed. 4. The last step of BSE after palpation is to express the nipple by gently squeezing the nipple. Any discharge should be brought to the attention of an HCP. Nipple discharge can be caused by many factors such as carcinoma, papilloma, pituitary adenoma, cystic breasts, and some medications.