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 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?
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.
Question 2 of 5
The nurse is caring for a client with breast cancer and removal of axillary lymph nodes. Which assessment finding is documented and brought to the physician's attention as potential lymphedema?
Correct Answer: C
Rationale: Enlargement of the arm is a key sign of lymphedema, which can occur after axillary lymph node removal due to impaired lymphatic drainage. A reddened area around the breast may indicate infection or inflammation, not lymphedema. Fluid accumulation under the axilla could be a seroma, not lymphedema. Pain in the chest wall is not specific to lymphedema.
Question 3 of 5
The nurse is caring for a client who is employed as a manual laborer. The client has recovered from a recent mastectomy and is planning to return to work. Which instruction from the nurse would be most helpful?
Correct Answer: C
Rationale: It is most helpful to provide an option that allows the client to continue employment at the current job, if the client is able. Many times, the client must continue employment and cannot change jobs. Instructing the client to not return to work may not be an option throughout the healing process, which could be up to 1 year. Asking others to do tasks and changing the job description are unrealistic throughout the recovery period.
Question 4 of 5
The nurse is caring for a client experiencing metastatic cancer-related pain. Which drug of choice does the nurse anticipate being ordered?
Correct Answer: C
Rationale: In treating clients with metastatic cancer-related pain, the opioid analgesics morphine (MS Contin) and fentanyl are the drugs most often used for pain relief. Morphine (MS Contin) can be given orally, rectally, subcutaneously, intravenously, intramuscularly, or by epidural catheter. Ibuprofen (Motrin) is given for mild to moderate pain. Alprazolam (Xanax) is provided to relieve anxiety. Propofol (Diprivan) is an anesthetic given, frequently for short procedures.
Question 5 of 5
The nurse is caring for four clients in an oncology unit. Following report, which client would the nurse identify as having the most life-threatening diagnosis?
Correct Answer: A
Rationale: The client with stage IV cancer, indicating metastasis, and receiving palliative care, which includes comfort measures, is in highest life-threatening condition. A client with a stage I tumor and no lymph node involvement has a good prognosis as the cancer has been caught at an early stage. A low blood count is common when the client is receiving chemotherapy. It is common to have chemotherapy and radiation as a treatment regimen. Clients have experienced good prognosis with estrogen receptor positive tumor treatment of oral chemotherapy.