Ricci Chapter 6 - Test Bank - 4th Edition || A+ Certified
Solutions.
1. The nurse is developing the discharge plan for a woman who has had a left-sided radical
mastectomy. The nurse is including instructions for ways to minimize lymphedema. Which
statement by the client indicates the need for additional instruction?
A. "I need to wear gloves when doing any gardening."
B. "Any blood pressures need to be taken in my right arm."
C. "I should wear clothing with elasticized sleeves."
D. "I need to avoid driving to and from work every day." Correct Answer: C
Rationale: Lymphedema increases when there is obstruction to the lymph flow. Wearing clothing
with elasticized sleeves would compress the extremity, possibly cause trauma, and obstruct the
flow, thus increasing the woman's risk. Wearing gloves when gardening and using the unaffected
arm for blood pressure readings help to reduce the risk of injury and subsequent lymphedema.
Driving would have no effect on lymphedema.
2. The nurse determines that a woman has implemented prescribed therapy for her fibrocystic
breast disease when the client reports that she has eliminated which from her lifestyle?
A. caffeine
B. cigarettes
C. dairy products
D. sweets Correct Answer: A
Rationale: Caffeine is a stimulant and eliminating it will help reduce symptoms of fibrocystic
breast disease. Cigarettes, dairy products, and sweets are not associated with symptoms of
fibrocystic breast disease.
3. A nurse has completed the assessment of a client. The nurse suspects that the client may have
a malignant breast mass based on which finding?
A. painful lump
B. absence of dimpling
C. regularly shaped mass
D. nipple retraction Correct Answer: D
Rationale: Malignant breast masses typically are difficult to palpate, painless, irregularly shaped,
and immobile, with nipple retraction and skin dimpling.
4. A woman who has undergone a right-sided modified-radical mastectomy returns from surgery.
Which nursing intervention would be most appropriate for the nurse to include in the client's
plan of care at this time?
A. Ask the client how she feels about having her breast removed.
B. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.
C. Encourage her to turn, cough, and deep breathe at frequent intervals.
D. Position her right arm below heart level. Correct Answer: C
Rationale: Upon return from surgery, the nurse should encourage the client to turn, cough, and
deep breathe at frequent intervals, at least every 2 hours, to help expand collapsed alveoli, clear
inhalation anesthetic agents from the body, and prevent postoperative atelectasis and pneumonia.
Asking the client how she feels about her breast removal should be done at a later time, when she
, is more alert and oriented and has had time to think about what has happened. The sign should
state that no BP, IV lines, and lab work should be done on the client's right arm. The right arm
should be elevated on a pillow to promote lymph drainage.
5. A 42-year-old woman is scheduled for a mammogram. Which statement would the nurse
include when teaching the woman about the procedure?
A. "The room will be darkened throughout the procedure."
B. "Each breast will be firmly compressed between two plates."
C. "Make sure to refrain from eating or drinking after midnight."
D. "A dye will be injected to highlight the breast tissue and its ducts." Correct Answer: B
Rationale: A mammogram involves taking X-ray pictures of the breasts while they are
compressed between two plastic plates. There is no need to darken the room or to refrain from
eating or drinking after midnight. A ductography involves the injection of dye to highlight the
breast ducts.
6. During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a
60-year-old woman's left breast. The nurse notifies the primary care provider. What would the
nurse anticipate the care provider to prescribe next?
A. mammogram
B. hormone receptor status
C. fine-needle aspiration
D. genetic testing for BRCA Correct Answer: A
Rationale: The characteristics of the palpated mass suggest that it is a benign mass, most likely a
fibroadenoma. However, since other breast lesions have similar characteristics, the lump needs to
be evaluated via mammography. Hormone receptor status is used to determine if a malignant
mass is stimulated to grow by estrogen or progesterone. A fine-needle aspiration may be done
later on if there is reason to suspect a malignancy. Genetic testing for the BRCA genes would be
done to determine a woman's risk for breast cancer, but this would not be done next.
7. A client with advanced breast cancer, who has had both chemotherapy and radiation therapy,
is to start endocrine therapy. Which agent would the nurse expect the client to receive?
A. trastuzumab
B. tamoxifen
C. cortisone
D. estrogen Correct Answer: B
Rationale: The objective of endocrine therapy is to block or counter the effect of estrogen in the
pathogenesis of cancer. The best-known agent is tamoxifen. Use of estrogens in postmenopausal
women increases a woman's risk for breast cancer. In addition, estrogen is a considered to play a
major role in the development of breast cancer and as such would not be used. Cortisone is a
steroid and would not be used. Trastuzumab is an immunotherapeutic agent.
8. As part of discharge planning, the nurse refers a woman to Reach to Recovery. The nurse
initiates this referral to facilitate which goal?
A. help support women who have undergone mastectomies
B. raise funds to support early breast cancer detection programs
C. provide all supplies needed after breast surgery for no cost
Solutions.
1. The nurse is developing the discharge plan for a woman who has had a left-sided radical
mastectomy. The nurse is including instructions for ways to minimize lymphedema. Which
statement by the client indicates the need for additional instruction?
A. "I need to wear gloves when doing any gardening."
B. "Any blood pressures need to be taken in my right arm."
C. "I should wear clothing with elasticized sleeves."
D. "I need to avoid driving to and from work every day." Correct Answer: C
Rationale: Lymphedema increases when there is obstruction to the lymph flow. Wearing clothing
with elasticized sleeves would compress the extremity, possibly cause trauma, and obstruct the
flow, thus increasing the woman's risk. Wearing gloves when gardening and using the unaffected
arm for blood pressure readings help to reduce the risk of injury and subsequent lymphedema.
Driving would have no effect on lymphedema.
2. The nurse determines that a woman has implemented prescribed therapy for her fibrocystic
breast disease when the client reports that she has eliminated which from her lifestyle?
A. caffeine
B. cigarettes
C. dairy products
D. sweets Correct Answer: A
Rationale: Caffeine is a stimulant and eliminating it will help reduce symptoms of fibrocystic
breast disease. Cigarettes, dairy products, and sweets are not associated with symptoms of
fibrocystic breast disease.
3. A nurse has completed the assessment of a client. The nurse suspects that the client may have
a malignant breast mass based on which finding?
A. painful lump
B. absence of dimpling
C. regularly shaped mass
D. nipple retraction Correct Answer: D
Rationale: Malignant breast masses typically are difficult to palpate, painless, irregularly shaped,
and immobile, with nipple retraction and skin dimpling.
4. A woman who has undergone a right-sided modified-radical mastectomy returns from surgery.
Which nursing intervention would be most appropriate for the nurse to include in the client's
plan of care at this time?
A. Ask the client how she feels about having her breast removed.
B. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.
C. Encourage her to turn, cough, and deep breathe at frequent intervals.
D. Position her right arm below heart level. Correct Answer: C
Rationale: Upon return from surgery, the nurse should encourage the client to turn, cough, and
deep breathe at frequent intervals, at least every 2 hours, to help expand collapsed alveoli, clear
inhalation anesthetic agents from the body, and prevent postoperative atelectasis and pneumonia.
Asking the client how she feels about her breast removal should be done at a later time, when she
, is more alert and oriented and has had time to think about what has happened. The sign should
state that no BP, IV lines, and lab work should be done on the client's right arm. The right arm
should be elevated on a pillow to promote lymph drainage.
5. A 42-year-old woman is scheduled for a mammogram. Which statement would the nurse
include when teaching the woman about the procedure?
A. "The room will be darkened throughout the procedure."
B. "Each breast will be firmly compressed between two plates."
C. "Make sure to refrain from eating or drinking after midnight."
D. "A dye will be injected to highlight the breast tissue and its ducts." Correct Answer: B
Rationale: A mammogram involves taking X-ray pictures of the breasts while they are
compressed between two plastic plates. There is no need to darken the room or to refrain from
eating or drinking after midnight. A ductography involves the injection of dye to highlight the
breast ducts.
6. During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a
60-year-old woman's left breast. The nurse notifies the primary care provider. What would the
nurse anticipate the care provider to prescribe next?
A. mammogram
B. hormone receptor status
C. fine-needle aspiration
D. genetic testing for BRCA Correct Answer: A
Rationale: The characteristics of the palpated mass suggest that it is a benign mass, most likely a
fibroadenoma. However, since other breast lesions have similar characteristics, the lump needs to
be evaluated via mammography. Hormone receptor status is used to determine if a malignant
mass is stimulated to grow by estrogen or progesterone. A fine-needle aspiration may be done
later on if there is reason to suspect a malignancy. Genetic testing for the BRCA genes would be
done to determine a woman's risk for breast cancer, but this would not be done next.
7. A client with advanced breast cancer, who has had both chemotherapy and radiation therapy,
is to start endocrine therapy. Which agent would the nurse expect the client to receive?
A. trastuzumab
B. tamoxifen
C. cortisone
D. estrogen Correct Answer: B
Rationale: The objective of endocrine therapy is to block or counter the effect of estrogen in the
pathogenesis of cancer. The best-known agent is tamoxifen. Use of estrogens in postmenopausal
women increases a woman's risk for breast cancer. In addition, estrogen is a considered to play a
major role in the development of breast cancer and as such would not be used. Cortisone is a
steroid and would not be used. Trastuzumab is an immunotherapeutic agent.
8. As part of discharge planning, the nurse refers a woman to Reach to Recovery. The nurse
initiates this referral to facilitate which goal?
A. help support women who have undergone mastectomies
B. raise funds to support early breast cancer detection programs
C. provide all supplies needed after breast surgery for no cost
