ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 54 : Caring for Clients With Breast Disorders Questions
Question 1 of 5
The nurse is caring for a client who has been diagnosed with a breast lump. The physician states that studies indicate a cancerous tumor in situ. The client is anxious and wants to know what may come next. The nurse is most correct to support physician instruction of which of the following?
Correct Answer: A
Rationale: The nurse is correct to restate the information that the physician has just discussed. Many times, anxious clients have a difficult time understanding information. The nurse realizes that a tumor that is in situ has developed in a localized area without invading the surrounding tissue. This criterion would allow the removal of tissue from only that area, not an entire mastectomy. When the client asks for the next step, chemotherapy and radiation, as indicated, would be initiated after removal of the tumor.
Question 2 of 5
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?
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.
Question 3 of 5
The nurse is caring for a client following breast reconstruction surgery using autogenous tissue. When assessing wounds from the surgical procedure, in which area would the nurse assess the wound from which tissue was taken?
Correct Answer: D
Rationale: The area in which tissue is taken for breast reconstruction surgery is from the rectus abdominis muscle in a manner similar to a 'tummy tuck.' The nurse must assess this site for healing or complications.
Question 4 of 5
The nurse is caring for a client who will be having artificial implants for breast reconstruction. The client is arriving at the physician's office for which procedure to be completed before the surgery can be done?
Correct Answer: B
Rationale: Before an implant for breast reconstruction can produce an optimum cosmetic appearance, the skin and tissue on the chest wall are expanded to provide a large enough space to fill and approximate the size of the remaining breast. The other options are not correct.
Question 5 of 5
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?
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.