Chapter 10

Question 1

1. A nurse is providing breast care education to a client after mammography. Which information regarding fibrocystic changes in the breast is important for the nurse to share?
   a. Fibrocystic breast disease is a disease of the milk ducts and glands in the breasts.
   b. It is a premalignant disorder characterized by lumps found in the breast tissue.
   c. Healthy women with fibrocystic breast disease find lumpiness with pain and tenderness in varying degrees in the breast tissue during menstrual cycles.
   d. Lumpiness is accompanied by tenderness after menses.

Answer 1

ANS: C
Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. The pain and tenderness fluctuate with the menstrual cycle. Fibrocystic changes are not premalignant changes; this information is inaccurate. Tenderness most often occurs before menses.

Question 2

2. A nurse is providing education to a support group of women newly diagnosed with breast cancer. It is important for the nurse to discuss which factor related to breast cancer with the group?
   a. Genetic mutations account for 50% of women who will develop breast cancer.
   b. Breast cancer is the leading cause of cancer death in women.
   c. In the United States, 1 in 10 women will develop breast cancer in her lifetime.
   d. The exact cause of breast cancer remains unknown.

Answer 2

ANS: D
The exact cause of breast cancer is unknown. Between 15% and 20% of these cancers are related to genetic mutations. Breast cancer is the second leading cause of cancer death in woman ages 45 to 55 years. One in eight women in the United States will develop breast cancer in her lifetime.

Question 3

3. Which diagnostic test is used to confirm a suspected diagnosis of breast cancer?
   a. Mammogram
   b. Ultrasound
   c. Needle-localization biopsy
   d. Magnetic resonance imaging (MRI)

Answer 3

ANS: C
When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a core-needle biopsy or a needle-localization biopsy. Mammography is a clinical screening tool that may aid in the early detection of breast cancers. Transillumination, thermography, and ultrasound breast imaging are being explored as methods for detecting early breast carcinoma. An MRI is useful in women with masses that are difficult to find (occult breast cancer).

Question 4

4. A healthy 60-year-old African-American woman regularly receives health care at her neighborhood clinic. She is due for a mammogram. At her first visit, her health care provider is concerned about the 3-week wait at the neighborhood clinic and made an appointment for her to have a mammogram at a teaching hospital across town. She did not keep her appointment and returned to the clinic today to have the nurse check her blood pressure. What is the most appropriate statement for the nurse to make to this client?
   a. “Do you have transportation to the teaching hospital so that you can get your mammogram?”
   b. “I’m concerned that you missed your appointment; let me make another one for you.”
   c. “It’s very dangerous to skip your mammograms; your breasts need to be checked.”
   d. “Would you like me to make an appointment for you to have your mammogram here?”

Answer 4

ANS: D
Offering to make an appointment for the client at the neighborhood location is nonjudgmental and gives her options as to where she may have her mammogram. Furthermore, it is an innocuous way to investigate the reasons the client missed her previous appointment. Mortality rates from breast cancer remain high for African-American women. Rather than reminding this woman that she has “missed her appointment,” discussing the evidence behind the recommendations for a mammogram might be preferable for the nurse. The nurse can offer to reschedule should the client agree to return for the test. Telling the client that it is dangerous to skip mammograms can be perceived as judgmental and derogatory and may alienate and embarrass the client.

Question 5

5. A client’s oncologist has just finished explaining the diagnostic workup results to her, and she still has questions. The woman states, “The physician says I have a slow-growing cancer. Very few cells are dividing. How does she know this?” What is the name of the test that gave the health care provider this information?
   a. Tumor ploidy
   b. S-phase index
   c. Nuclear grade
   d. Estrogen-receptor assay

Answer 5

ANS: B
The S-phase index measures the number of cells in the synthesis phase of cell development. If the number of cells noted is high, then the cancer is growing at a fast rate. In this client’s case, her S-phase index is assumed to be low. Tumor ploidy is the amount of deoxyribonucleic acid (DNA) in a tumor cell, compared with that in a normal cell. Nuclear grade describes the degree of abnormalities present in the cancer cell tubules, the nuclei morphologic features, and mitotic rates. Estrogen and progesterone receptors are proteins found in the cell cytoplasm and surface of some breast cancer cells.

Question 6

6. Breast pain occurs in many women during their perimenopausal years. Which information is a priority for the nurse to share with the client?
   a. Breast pain is an early indication of cancer.
   b. Pain is almost always an indication of a solid mass.
   c. Distinguishing between cyclical and noncyclical pain is important.
   d. Breast pain is most often treated with narcotics.

Answer 6

ANS: C
Breast pain is unusual in breast cancer. Solid masses are generally benign and described as smooth, round, mobile, and painless. Distinguishing between cyclical and noncyclical pain is important to determine whether the cause is hormonal. Idiopathic pain is most often treated with nonsteroidal antiinflammatory medications.

Question 7

7. After a mastectomy, which activity should the client be instructed to avoid?
   a. Emptying surgical drains twice a day and as needed
   b. Lifting more than 4.5 kg (10 lb) or reaching above her head until given permission by her surgeon
   c. Wearing clothing with snug sleeves to support the tissue of the arm on the operative side
   d. Immediately reporting inflammation that develops at the incision site or in the affected arm

Answer 7

ANS: C
The woman should not be advised to wear snug clothing. She should be advised to avoid tight clothing, tight jewelry, and other apparel that might cause decreased circulation in the affected arm. As part of the teaching plan, the woman should be instructed to empty the surgical drains twice a day, to avoid lifting more than 4.5 kg (10 lb) or reaching above her head until given permission by her surgeon, and to report immediately any inflammation that develops at the incision site or in the affected arm.

Question 8

8. A health care provider performs a clinical breast examination on a woman diagnosed with fibroadenoma. How would the nurse explain the defining characteristics of a fibroadenoma?
   a. Inflammation of the milk ducts and glands behind the nipples
   b. Thick, sticky discharge from the nipple of the affected breast
   c. Lumpiness in both breasts that develops 1 week before menstruation
   d. Single lump in one breast that can be expected to shrink as the woman ages

Answer 8

ANS: D
Fibroadenomas are characterized by discrete, usually solitary lumps smaller than 3 cm in diameter. Fibroadenomas increase in size during pregnancy and shrink as the woman ages. Inflammation of the milk ducts and glands behind the nipples is associated with mammary duct ectasia, not fibroadenoma. Thick, sticky discharge from the nipple of the affected breast is associated with galactorrhea, not fibroadenoma. Lumpiness in both breasts that develops 1 week before menstruation is associated with fibrocystic changes of the breast, not fibroadenoma.

Question 9

9. What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?
   a. The blood pressure (BP) cuff should not be applied to the affected arm.
   b. Venipuncture for blood work should be performed on the affected arm.
   c. The affected arm should be used for intravenous (IV) therapy.
   d. The affected arm should be held down close to the woman’s side.

Answer 9

ANS: A
The affected arm should not be used for BP readings, IV therapy, or venipuncture. The affected arm should be elevated with pillows above the level of the right atrium.

Question 10

10. A woman has a breast mass that is not well delineated and is nonpalpable, immobile, and nontender. Which condition is this client experiencing?
    a. Fibroadenoma
    b. Lipoma
    c. Intraductal papilloma
    d. Mammary duct ectasia

Answer 10

ANS: C
Intraductal papilloma is the only benign breast mass that is nonpalpable. Fibroadenoma is well delineated, palpable, and movable. Lipoma is palpable and movable. Mammary duct ectasia is not well delineated and is immobile, but it is palpable and painful.

Question 11

11. A client is concerned because she has been experiencing some milky, sticky breast discharge. Which nonmalignant condition is exhibited with this finding?
    a. Relative inflammatory lesion
    b. Galactorrhea
    c. Mammary duct ectasia
    d. Breast infection

Answer 11

ANS: B
Galactorrhea bilaterally exhibits a spontaneous, milky, and sticky discharge and is a normal finding during pregnancy; however, it may also occur as the result of elevated prolactin levels. Prolactin can become elevated as a result of a thyroid disorder, pituitary tumor, stress, coitus, trauma, or chest wall surgery.

Question 12

12. A client has been prescribed adjuvant tamoxifen therapy. What common side effect might she experience?
    a. Weight gain, hot flashes, and blood clots
    b. Vomiting, weight loss, and hair loss
    c. Nausea, vomiting, and diarrhea
    d. Hot flashes, weight gain, and headaches

Answer 12

ANS: A
Common side effects of tamoxifen therapy include hot flashes, weight gain, and blood clots. Weight loss, hair loss, diarrhea, and headaches are not common side effects of tamoxifen.

Question 13

13. Fibrocystic changes in the breast most often appear in women in their 20s and 30s. Although the cause is unknown, an imbalance of estrogen and progesterone may be the cause. The nurse who cares for this client should be aware that treatment modalities are conservative. Which proven modality may offer relief for this condition?
    a. Diuretic administration
    b. Daily inclusion of caffeine in the diet
    c. Increased vitamin C supplementation
    d. Application of cold packs to the breast as necessary

Answer 13

ANS: A
Diuretic administration plus a decrease in sodium and fluid intake are recommended. Although not supported by research, some advocate eliminating dimethylxanthines (caffeine) from the diet. Smoking should also be avoided, and alcohol consumption should be reduced. Vitamin E supplements are recommended; however, the client should avoid megadoses because vitamin E is a fat-soluble vitamin. Pain relief measures include applying heat to the breast, wearing a supportive bra, and taking nonsteroidal antiinflammatory drugs.

Question 14

14. What is the correct name describing a benign breast condition that includes dilation and inflammation of the collecting ducts?
    a. Mammary duct ectasia
    b. Intraductal papilloma
    c. Chronic cystic disease
    d. Fibroadenoma

Answer 14

ANS: A
Generally occurring in women approaching menopause, mammary duct ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge. Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts. Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated. Fibroadenoma is evidenced by fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules.

Question 15

15. Which client is most at risk for fibroadenoma of the breast?
    a. 38-year-old woman
    b. 50-year-old woman
    c. 16-year-old girl
    d. 27-year-old woman

Answer 15

ANS: C
Although it may occur at any age, fibroadenoma is most common in the teenage years. Ductal ectasia and intraductal papilloma become more common as a woman approaches menopause. Fibrocystic breast changes are more common during the reproductive years.

Question 16

16. Which client should the nurse refer for further testing?
    a. Left breast slightly smaller than right breast
    b. Eversion (elevation) of both nipples
    c. Faintly visible bilateral symmetry of venous network
    d. Small dimple located in the upper outer quadrant of the right breast

Answer 16

ANS: D
A small dimple is an abnormal finding and should be further evaluated. Nipple retraction and a dimpling or pitting of the skin is suggestive of a locally advanced, aggressive form of breast cancer. In many women, one breast is smaller than the other, and eversion of both nipples is a normal finding. Faintly visible venous network is also a normal finding.

Question 17

17. The most conservative approach for early breast cancer treatment involves lumpectomy followed by which procedure?
    a. Radiation
    b. Adjuvant systemic therapy
    c. Hormonal therapy
    d. Chemotherapy

Answer 17

ANS: A
Radiation therapy, in the form of either brachytherapy or accelerated breast radiation, is the standard therapy after lumpectomy for the treatment of early-stage breast cancer. Chemotherapy administered soon after surgical removal of the tumor is referred to as adjuvant chemotherapy. Not all women are candidates for hormonal therapy. After the entire tumor or portion is removed by excision, a receptor assay must be performed. Chemotherapy with multiple-drug combinations is used in the treatment of recurrent and advanced breast cancer with positive results.

Question 18

18. Macromastia, or breast hyperplasia, is a condition in which women have very large and pendulous breasts. Breast hyperplasia can be corrected with a reduction mammoplasty. Which statement regarding this procedure is the most accurate?
    a. Breast reduction surgery is covered by insurance.
    b. Breastfeeding might be difficult.
    c. No sequelae after the procedure is known.
    d. Pain in the back and shoulders may not be relieved.

Answer 18

ANS: B
If breast reduction surgery is performed, then establishing breastfeeding at a later date may be difficult. Macromastia may not be covered by all insurance companies. A consequence of surgery may be decreased sensation and pain, secondary to scar tissue. Reduction mammoplasty will relieve chronic neck and back pain.

Question 19

19. Having a genetic mutation may create an 85% chance of developing breast cancer in a woman’s lifetime. Which condition does not increase a client’s risk for breast cancer?
    a. BRCA1 or BRCA2 gene mutation
    b. Li-Fraumeni syndrome
    c. Paget disease
    d. Cowden syndrome

Answer 19

ANS: C
Paget disease originates in the nipple and causes nipple carcinoma and exhibits bleeding, oozing, and crusting of the nipple. BRCA1 or BRCA2, Li-Fraumeni syndrome, and Cowden syndrome are all genetic mutations that have different family pedigrees and increase the risk of breast cancer.

Question 20

20. A client is scheduled for surgery after a recent breast cancer diagnosis. The nurse is discussing the procedure with the client. To allay her fears, which explanation best describes a skin-sparing mastectomy?
    a. Removal of the breast, nipple, and areola, leaving only the skin
    b. Removal of the breast, nipple, areola, and axillary node dissection
    c. Incision on the outside of the breast, leaving the nipple intact
    d. Removal of both breasts in their entirety

Answer 20

ANS: A
A skin-sparing mastectomy is a special procedure that keeps the outer breast of the skin intact. The breast, nipple, and areola are removed. A tissue expander may be placed for later reconstruction. A modified radical mastectomy also removes the axillary lymph nodes. The nipple-sparing mastectomy is reserved for a small number of women during which the areola is removed leaving the nipple intact. Women who test positive for the BRCA1 or BRCA2 gene mutation may have both breasts removed to reduce the risk of cancer and is most commonly known as a prophylactic or preventative mastectomy.

Question 21

1. Researchers have found a number of common risk factors that increase a woman’s chance of developing a breast malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? (Select all that apply.)
   a. Family history
   b. Late menarche
   c. Early menopause
   d. Race
   e. Nulliparity or first pregnancy after age 40 years

Answer 21

ANS: A, D, E
Family history, race, and nulliparity or the first pregnancy after age 40 years are known risk factors for the development of breast cancer. Others risk factors include age, personal history of cancer, high socioeconomic status, sedentary lifestyle, hormone replacement therapy, recent use of oral contraceptives, never having breastfed a child, and drinking more than one alcoholic beverage per day. Early menarche and late menopause are not risk factors for breast malignancy.

Question 22

2. Cellulitis with or without abscess formation is a fairly common condition. The nurse is providing education for a client whose presentation to the emergency department includes an infection of the breast. Which information should the nurse share with this client? (Select all that apply.)
   a. Nipple piercing may be the cause of a recent infection.
   b. Treatment for cellulitis will include antibiotics.
   c. Streptococcus aureus is the most common pathogen.
   d. Obesity, smoking, and diabetes are risk factors.
   e. Breast is pale in color and cool to the touch.

Answer 22

ANS: A, B, D
The at-risk population for breast infection shares characteristics such as large breasts, obesity, previous surgeries, sebaceous cysts, smoking, diabetes, and recent nipple piercing. The most common pathogen is Staphylococcus aureus. Presentation of cellulitis of the breast includes pain, reddening, and warmth to the touch; treatment includes antibiotics and/or aspiration.

Question 23

3. Guidelines for breast cancer screening continue to evolve as new evidence is generated. Which examination or procedure and frequency would be recommended for a 31-year-old asymptomatic client? (Select all that apply.)
   a. Annual mammography
   b. Clinical breast examination every 3 years
   c. Annual MRI
   d. Breast self-examination
   e. Mammography every 3 years

Answer 23

ANS: B, D
A 31-year-old client with no risk factors and who is asymptomatic should perform breast self-examination on a regular basis and have a clinical breast examination every 3 years. Women who are 40 years of age and older require both mammography and clinical breast examination annually. High-risk women 30 years and older should have an annual MRI and mammogram.

Question 24

4. Chemotherapy with multiple drug agents is used in the treatment of recurrent and advanced breast cancer with positive results. Which side effects would the nurse anticipate for the client once treatment has begun? (Select all that apply.)
   a. Hair loss
   b. Severe constipation
   c. Anemia
   d. Leukopenia
   e. Thrombocytopenia

Answer 24

ANS: A, C, D, E
Because chemotherapeutic agents rapidly kill reproducing cells, treatment also affects normal cells that frequently reproduce. The side effects that the nurse would anticipate and on which the nurse will provide education include partial or full hair loss, gastrointestinal effects (e.g., nausea, vomiting, anorexia, mucositis), leukopenia, neutropenia, thrombocytopenia, and anemia.

Question 25

Self-care instructions for a woman who has undergone a modified radical mastectomy include that she should:
A. Wear clothing with snug sleeves to support her affected arm.
B. Use depilatory creams instead of shaving the axilla of her affected arm.
C. Expect a decrease in sensation or tingling in her affected arm as her body heals.
D. Empty surgical drains once a day or every other day.

Answer 25

Ans: C
A decrease in sensation and tingling in the affected arm and in the incision are expected for weeks to months after the surgery. Loose clothing should be worn because tight clothing could impede circulation in the affected arm. The axilla of the affected arm should not be shaved nor should depilatory creams or strong deodorants be used. Drains should be emptied at least twice a day, and more often if necessary.

Question 26

The nurse should refer a client for further testing if which of the following was noted on inspection of a 55-year-old woman’s breasts:
A. Left breast slightly smaller than right breast
B. Eversion (elevation) of both nipples
C.Bilateral symmetry of venous network, which is faintly visible
D.Small dimple located in the upper outer quadrant of the right breast

Answer 26

Ans: D
A small dimple is an abnormal finding and should be further evaluated. In many women, one breast is smaller than the other. Eversion of both nipples and a faintly visible venous network are both normal findings.

Question 27

Fibrocystic changes in the breast most often appear in women in their 20s and 30s. The etiology is not known, but it may be an imbalance of estrogen and progesterone. The nurse who cares for a client with such changes should be aware that treatment modalities are conservative. One proven modality that may provide relief is:
A. Diuretic administration
B. Including caffeine daily in the diet
C. Increased vitamin C supplementation
D. Application of cold packs to the breast as necessary

Answer 27

Ans: A
Diuretic administration plus a decrease in sodium and fluid intake are recommended. Although not supported by research, eliminating dimethylxanthines (caffeine) from the diet has been advocated. Smoking should also be avoided, and alcohol consumption reduced. Vitamin E supplements are recommended; however, the client should avoid megadoses because this is a fat-soluble vitamin. Pain relief measures include applying heat to the breast, wearing a supportive bra, and taking nonsteroidal anti-inflammatory drugs.

Question 28

A client has been prescribed adjuvant tamoxifen therapy. What common side effects might she experience?
A. Nausea, hot flashes, and vaginal bleeding
B. Vomiting, weight loss, and hair loss
C. Nausea, vomiting, and diarrhea
D. Hot flashes, weight gain, and headaches

Answer 28

Ans: A
Common side effects of tamoxifen therapy include hot flashes, nausea, vomiting, vaginal bleeding, menstrual irregularities, and rash. The other side effects listed are not commonly seen with this therapy.

Question 29

The most conservative approach for early breast cancer treatment involves lumpectomy followed by which procedure?
  A. Radiation therapy
  B, Adjuvant systemic therapy
  C. Hormonal therapy
  D. Chemotherapy

Answer 29

Ans: A
Radiation therapy, in the form of either brachytherapy or accelerated breast irradiation, is the standard therapy after lumpectomy for the treatment of early-stage breast cancer. Chemotherapy administered soon after surgical removal of the tumor is referred to as adjuvant chemotherapy. Not all women are candidates for hormonal therapy; after the entire tumor or portion is removed by excision, a receptor assay must be done. Chemotherapy with multiple-drug combinations is used in the treatment of recurrent and advanced breast cancer, with positive results.

Question 30

A patient has been prescribed raloxifene hydrochloride (Evista) for treatment of breast cancer. Which finding, if noted by the nurse prior to medication administration, would lead to immediate contact with the physician?
A. CBC result indicates a slight decrease in red blood cell count.
B. PMH noted of superficial thrombophlebitis of the left leg.
C. Family history of osteoporosis.
D. Leukemoid reaction noted on CBC findings.

Answer 30

Ans: B
A PMH of thrombophlebitis is a significant risk factor for clot formation and stroke with the use of this medication, so the provider should be notified immediately so as to evaluate the clinical indication for this medication type. A slightly decreased red blood cell count would not warrant immediate notification of the provider; the patient should receive follow-up monitoring. Evista is also used as part of a treatment protocol for osteoporosis, so there is no need to notify the provider about this finding. A leukemoid reaction (an increase in white blood cell [WBC] count), is usually self-limiting, and although the provider should be notified, immediate notification is not necessary unless the increase is significant; the nurse should perform further investigation to assess the results of this test.

Question 31

Which clinical findings would be shared in the presentation of fibrocysts and fibroadenoma?
 A. Moveable
 B. Single lump
 C. Firm
 D. No nipple discharge

Answer 31

Ans: A
Both fibrocysts and fibroadenoma are considered to be moveable breast masses. Fibrocysts are multiple lumps, whereas fibroadenoma is a single lump. Fibrocystic masses can be firm or soft, whereas fibroadenomas are firm. Fibrocystic masses may or may not have nipple discharge, whereas fibroadenomas do not.

Question 32

The pathology reports indicate that a breast tumor has reached the chest wall. On the basis of this finding, the nurse would interpret the result as which stage?
A.  IV
 B. I
C.  IIA
 D. IIIB

Answer 32

Ans: D
Stage IIIB indicates that the tumor has direct extension to the chest wall or skin. Stage IV would involve metastasis, and there is no information here to indicate it. Stage I identifies small negative lymph nodes. Stage IIA indicates a tumor with positive nodes.

Question 33

A 38-year-old woman is screened for breast cancer risk and is found to be at high risk for it. She has no immediate health presentations. Which priority action should be taken as part of her treatment therapy?
A. Refer to the surgeon for discussion of mastectomy.
B. Instruct the patient on how to perform a self–breast exam on a monthly basis.
C. Schedule an MRI and mammogram after consultation with her health care provider.
D. Schedule an ultrasound and, based on the results, schedule an MRI.

Answer 33

Ans: C
Because the patient has already been identified as being at high risk, baseline testing with an MRI and mammogram (ultrasound is not indicated) should be established on a yearly basis because of her age. At this time, there is no reason to refer her to a surgeon for discussion of a surgical intervention because she may have an increased lifetime risk of only 20%, and other investigations may be warranted at this time. Although self–breast examination is important, it is not the immediate priority at this time.