Chapter 63Breast Alterations: Nursing Management My Nursing Test Banks

Chapter 63Breast Alterations: Nursing Management

MULTIPLE CHOICE

1.A client who has just given birth is planning on breastfeeding the baby. The nurse realizes that which of the following hormones influences breast milk secretion?

1.

Follicle-stimulating hormone

2.

Luteinizing hormone

3.

Oxytocin

4.

Prolactin

ANS: 4

Prolactin is necessary for breast formation and the production of breast milk. Oxytocin is responsible for uterine contractions and the breast milk let down. Follicle-stimulating hormone stimulates the production of sperm and ova. In men, luteinizing hormone stimulates testosterone needed for sperm production, and in women, it stimulates ovulation.

PTS:1DIF:Analyze

REF:Breast Alternations during Maturational Phases: Effects of Hormones on Breast Tissue; Changes During Pregnancy

2.The nurse is instructing a female client about breast self-examination. Which of the following instructions would not be correct for the nurse to provide?

1.

A menstruating woman should check her breast monthly 8 days following her menses.

2.

An inverted nipple is not a cause for alarm.

3.

During menopause, you should check your breasts once a month during the same time frame.

4.

Visually check the breasts in front of a mirror.

ANS: 2

An inverted nipple is not necessarily a cause for alarm if it has been present since puberty, but any change in the nipple or breast tissue should be evaluated. The other instructions would be appropriate for the nurse to provide.

PTS: 1 DIF: Apply REF: Examination of the Breast

3.A client who has been breastfeeding a newborn for the last 3 months is experiencing an inflammation of the breast. The nurse realizes this client is experiencing:

1.

intraductal papilloma.

2.

mastalgia.

3.

mastitis.

4.

mastodynia.

ANS: 3

Mastitis, inflammation of the breast, may be caused from irritation, injury, or infection, and it most commonly occurs within the first 3 months after childbirth. Mastalgia and mastodynia are terms that refer to breast pain. Intraductal papilloma is a small benign tumor that grows within the terminal portion of a solitary milk duct of the breast.

PTS: 1 DIF: Analyze REF: Mastitis

4.During the examination of a female clients breasts, the nurse determines that which of the following assessment findings would be normal?

1.

Nipple discharge

2.

Masses

3.

Scaling

4.

Symmetrical nipples

ANS: 4

Symmetrical nipples would be considered a normal finding. All the other options are abnormal findings.

PTS: 1 DIF: Analyze REF: Examination of the Breast

5.The nurse is instructing a female client on the importance of having routine mammograms because mammograms:

1.

can detect masses before they become palpable.

2.

involves no radiation.

3.

has a 25% rate of false positives.

4.

combines a blood test with radiology.

ANS: 1

Mammography is a radiological procedure that is useful because it allows visualization of benign and malignant disorders before they become palpable. The rate of false positives is 5% to 10%. Mammography does use radiation. Mammography does not include a blood test.

PTS: 1 DIF: Apply REF: Diagnostic Tests: Mammography

6.The nurse is instructing a female client on what should be done if a lump is discovered while performing breast self-examination (BSE). What should the nurse instruct the client to do?

1.

Call her physician and immediately schedule an appointment.

2.

Call to schedule an appointment next month.

3.

Take the antibiotics she has in her medicine cabinet.

4.

Wait until next months BSE to make sure the lump is still there.

ANS: 1

Follow-up on a lump should begin immediately. The client should not wait to see if the lump remains or changes, and she should not medicate herself.

PTS: 1 DIF: Apply REF: Examination of the Breast

7.The nurse determines that a female client has a lower risk for developing breast cancer when which of the following is assessed?

1.

Alcohol intake

2.

Breastfeeding

3.

Obesity

4.

Smoking

ANS: 2

Breastfeeding has consistently been shown to decrease a womans risk of breast cancer. The other options increase a womans risk of breast cancer.

PTS: 1 DIF: Analyze REF: Breast Cancer: Etiology

8.The nurse should instruct the client that when performing a breast self-examination, pay particular attention to which of the following areas since the greatest number of malignancies are found in this breast area?

1.

Upper outer quadrant of the breast to the axilla

2.

Portion of the breast closest to the xiphoid process

3.

Portion of the breast closest to the abdomen

4.

Portion of the breast closest to the neck

ANS: 1

The upper outer quadrant of the breast to the axilla is an area that needs to be evaluated since the greatest proportion of malignancies are found in this area of the breast. The other breast areas need to be examined; however, special attention should be given to the upper outer quadrant.

PTS: 1 DIF: Apply REF: Examination of the Breast

9.The nurse should instruct a client, diagnosed with mastalgia, to do which of the following?

1.

Have an immediate mammogram.

2.

Expect to need a biopsy.

3.

Decrease the intake of caffeine.

4.

Determine if breast augmentation surgery is desired.

ANS: 3

Mastalgia refers to breast pain. Pain is not generally associated with breast cancer. Wearing a well-fitting supportive brassiere during exercise and decreasing the intake of caffeine would be beneficial. The client does not need an immediate mammogram, a biopsy, or breast augmentation.

PTS: 1 DIF: Apply REF: Mastodynia and Mastalgia

10.A female client tells the nurse that she is planning on having plastic surgery to correct a minor facial defect and then have her breasts done. The nurse would identify which of the following nursing diagnoses as being appropriate for this client?

1.

Ineffective coping

2.

Anxiety

3.

Hopelessness

4.

Body dysmorphic disorder

ANS: 4

Body dysmorphic disorder is characterized by a preoccupation with body image and the slight or imagined defect in appearance that leads to impairment or distress in functioning in social situations. Body dysmorphic disorder would be appropriate for the client who is planning on having plastic surgery for a minor facial defect and then breast augmentation surgery. The other nursing diagnoses would not be appropriate for the client at this time.

PTS: 1 DIF: Analyze REF: Breast Alterations: Psychological Aspects

11.The nurse is determining if a female client is at risk for benign breast disease. Which of the following is a risk factor for this disorder?

1.

Smoking

2.

Caffeine use

3.

Alcohol intake

4.

Age 55

ANS: 2

Risk factors for benign breast disease include caffeine use, imbalance between estrogen and progesterone, estrogen excess, hyperprolactemia, and age between 20 to 50 years. Smoking and alcohol intake are not risk factors for benign breast disease.

PTS: 1 DIF: Analyze REF: Red Flag: Risk Factors for Benign Breast Disease

12.A client is scheduled for a prophylactic mastectomy. The nurse should remind the client that skin flaps will be left after the surgery for:

1.

reconstruction.

2.

suturing to the chest wall.

3.

possible use for other skin disorders.

4.

donation for someone needing a skin transplant.

ANS: 1

The goal of a mastectomy is to remove all breast tissue, including the nipple and areola, while leaving well-perfused viable skin flaps for primary closure or reconstruction. The skin flaps will not be sutured to the chest wall. The skin flaps are not for use for other skin disorders. The skin flaps are not for donation for someone needing a skin transplant.

PTS: 1 DIF: Apply REF: Mastectomy

MULTIPLE RESPONSE

1.When instructing a client on breast self-examination, the nurse reviews the importance of visual inspection of the breasts. Which of the following should the nurse instruct the client to focus on when doing this part of the examination? (Select all that apply.)

1.

Contour and symmetry of the breasts

2.

Skin changes

3.

Position of the nipples

4.

Presence or absence of masses

5.

Pain

6.

Size

ANS: 1, 2, 3, 4

Visual inspection of the breast self-examination focuses on the contour and symmetry of the breasts; skin changes such as scaling, puckering, dimpling, or scars; the position of the nipples; nipple discharge or retraction; and presence or absence of masses. This part of the examination does not include pain or size of the breasts.

PTS: 1 DIF: Apply REF: Examination of the Breast

2.The nurse is preparing to assess a clients nipples during a breast examination. Which of the following are considered pathological conditions that affect the nipple? (Select all that apply.)

1.

Bleeding

2.

Lumps

3.

Discharge

4.

Scars

5.

Fissures

6.

Large size

ANS: 1, 3, 5

The three primary pathological conditions of the nipple include bleeding, discharge, and fissures. Lumps, scars, and size are not associated with pathological conditions of the nipple.

PTS:1DIF:AnalyzeREF:Nipple Disorders

3.Which of the following should the nurse do if a female client is experiencing nipple discharge? (Select all that apply.)

1.

Note the color of the discharge.

2.

Determine if the discharge is from one or both breasts.

3.

Obtain a sample of the discharge with a sterile cotton-tipped swab.

4.

Assess the nipple drainage for occult blood

5.

Apply sterile bandages over the nipple.

6.

Pad the clients bra with gauze.

ANS: 1, 2, 3, 4

If a female client is assessed with abnormal nipple discharge, the nurse should note the color of the discharge; determine if the discharge is from one or both breasts; obtain a sample of the discharge with a sterile cotton-tipped swab; and assess the drainage for occult blood. The nurse should not apply sterile bandages over the nipple nor pad the clients bra with gauze.

PTS: 1 DIF: Apply REF: Red Flag: Examining Nipple Discharge

4.A client is experiencing galactorrhea. Which of the following should the nurse assess in this client? (Select all that apply.)

1.

Recent vigorous nipple stimulation

2.

Prescribed hormones, blood pressure medications, or antidepressants

3.

Intake of herbal remedies such as fennel or anise

4.

Use of street drugs such as opiates and marijuana

5.

Recent chest trauma

6.

Age of menarche

ANS: 1, 2, 3, 4, 5

Galactorrhea is the secretion of a milk-like fluid in a non-lactating breast. This can occur because of recent vigorous nipple stimulation, prescribed hormones, blood pressure medication, or antidepressants; intake of herbal remedies such as fennel or anise; use of street drugs such as opiates and marijuana; and recent chest trauma. Age of menarche will not help determine the cause for the disorder.

PTS:1DIF:ApplyREF:Galactorrhea

5.A client is considering breast augmentation surgery. Which of the following postoperative complications should the nurse discuss with the client regarding this surgery? (Select all that apply.)

1.

Change in sensation

2.

Development of a hematoma

3.

Fibrous tissue around the implant

4.

Heart palpitations

5.

High blood pressure

6.

Arm pain

ANS: 1, 2, 3

Postoperative complications with breast augmentation include change in sensation, development of a hematoma; and formation of fibrous tissue around the implant. Heart palpitations, high blood pressure, and arm pain are not considered postoperative complications of breast augmentation surgery.

PTS:1DIF:ApplyREF:Breast Augmentation

Leave a Reply