Breast Cancer
A nurse is conducting a health-promotion workshop to a group of females in their 40s and 50s. Which of the following points about nipple discharge should the nurse teach to participants?
Unexpected nipple discharge of any type warrants medical follow-up.
Although most cases of nipple discharge are not related to malignancy, further assessment is indicated. Galactorrhea is not considered a normal age-related change, nor is it a common perimenopausal symptom.
Which of the following nursing interventions is most appropriate to enhance oxygenation in a client with unilateral malignant lung disease?
Positioning client with “good lung down”
Therapeutic positioning identifies the best position for the client assuring stable oxygenation status. Research indicates that positioning the client with the unaffected lung (good lung) dependent best promotes oxygenation in clients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
The nurse is admitting a male client for a total knee replacement who states during the health history interview no problems with urinary elimination except that the “stream is less than it used to be.” The nurse would give the client anticipatory guidance that which of the following conditions is likely to be developing?
Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80.
The nurse is caring for an admitted client with abdominal pain, nausea, and vomiting. The client has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which of the following types of bowel sounds that is consistent with the client’s clinical picture?
High pitched and hyperactive above the area of obstruction
Early in intestinal obstruction, the client’s bowel sounds are hyperactive and high pitched, sometimes referred to as “tinkling” above the level of the obstruction. This occurs because peristaltic action increases to “push past” the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.
The nurse is caring for a client who has recently been diagnosed with stage II cervical cancer. Which of the following characteristics should the nurse understand related to this stage?
It has spread locally.
Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ; stage III denotes extensive regional spread, and stage IV denotes metastasis.
The nurse is caring for a client diagnosed with breast cancer who just underwent an axillary lymph node dissection. Which of the following interventions should the nurse use to decrease the lymphedema?
Assess blood pressure on the unaffected arm only.
Blood pressure readings, venipunctures, and injections should not be done on the affected arm. Elastic bandages should not be used in the early postoperative period because they inhibit collateral lymph drainage. The affected arm should be elevated above the heart, and isometric exercises are recommended to reduce fluid volume in the arm.
The nurse is planning care for a client with metastatic lung cancer who has a 60-pack-per-year history of cigarette smoking. Which of the following respiratory defences is impaired related to tobacco use?
Mucociliary clearance
Smoking decreases the ciliary action in the tracheo-bronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
To accurately monitor progression of the symptom of decreased urinary stream, the nurse should encourage the client to have which of the following primary screening measures done on a regular basis?
Digital rectal examination (DRE)
Digital rectal examination (DRE) is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia in men over 50 years of age.
The nurse is planning care for a client with an abdominal mass and suspected bowel obstruction. Which of the following factors in the client’s history increases the client’s risk for colorectal cancer?
History of rectal polyps
A history of rectal polyps places this client at risk for colorectal cancer. This tissue can degenerate over time and become malignant. The other factors identified do not pose additional risk to the client.
Previous administrations of chemotherapy agents to a client with cancer have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend?
A low-residue, low-fibre diet
Clients experiencing diarrhea secondary to chemotherapy or radiation therapy (or both) often benefit from a diet low in seasonings and roughage. Fresh fruits and vegetables are high in fibre and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.
The nurse has been asked to participate in a healthy living workshop. While teaching about women’s health, which of the following guidelines should the nurse provide to the audience?
“It’s recommended that you discuss the risks and benefits of mammograms with your health care provider when you turn 40.”
Women ages 40–49 should discuss individual risk for breast cancer, along with the risks and benefits of mammography, with their health care provider. Women ages 50–69 should undergo mammography every two years. Mammograms are recommended for all women, not solely those with a family history of breast cancer. Breast self-examination (BSE) is not a replacement for mammography and clinical breast examinations are not necessary at each office visit.
The nurse is assisting a client with metastatic lung cancer to ambulate when the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is best for the nurse to implement?
Obtain a prescription for supplemental oxygen to be used during ambulation and other activity.
An oxygen saturation level that drops below 90% with activity indicates that the client is not tolerating the exercise and needs to use supplemental oxygen.
The nurse is caring for a client who is one day postoperative following a transurethral resection of the prostate (TURP). Which of the following events should the nurse prioritize for intervention?
The client’s continuous bladder irrigation (CBI) is infusing, but output has decreased.
A decrease or cessation of output in a client with continuous bladder irrigation (CBI) requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the client or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the client’s CBI.
The nurse is caring for a client following bowel resection and has a nasogastric tube to suction, but symptoms of nausea and abdominal distension. The nurse irrigates the tube prn as prescribed, but the irrigating fluid does not return. Which of the following actions is priority?
Reposition the tube and check for placement.
The tube may be resting against the stomach wall. The first action by the nurse, since this is intestinal surgery (not gastric surgery), is to reposition the tube and check it again for placement.
Which of the following items would be most beneficial when providing oral care to a client with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy?
1 tsp salt in 1 L water mouth rinse
A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is an adverse effect of chemotherapy.
The nurse is volunteering at a community centre to teach women regarding breast cancer. The nurse would include which of the following risk factors when discussing breast cancer? (Select all that apply.)
The nurse is admitting a client who has diagnosed with non–small cell carcinoma of the lung. Which of the following risk factors should the nurse assess in the client related to this type of cancer? (Select all that apply.)
The nurse is preparing a client with a diagnosis of benign prostatic hyperplasia (BPH) for surgery. Which of the following goals is the primary goal of this intervention?
Resumption of normal urinary drainage
The most significant signs and symptoms of benign prostatic hyperplasia (BPH) relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. Surgery is performed primarily to resolve these problems. Fluid imbalances, problems with sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.
Two days following a colectomy for an abdominal mass, a client reports gas pains and abdominal distension. The nurse plans care for the client based on the knowledge that the symptoms occur as a result of which of the following?
Impaired peristalsis
Until peristalsis returns to normal following anaesthesia, the client may experience slowed gastrointestinal motility leading to gas pains and abdominal distension.
The nurse is caring for a client suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the client’s nutritional intake?
Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as ensure, peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the client will eat.
The nurse is caring for a client who has a three-week-old infant and she is breastfeeding. The client has sought care because of recent breast tenderness, redness, and fever. Which of the following teaching points should the nurse prioritize when following up her care?
Ensure client adheres to her prescribed antibiotic regimen.
Mastitis normally requires antibiotic therapy, the success of which is often dependent on close adherence to the prescribed regimen. Breastfeeding should indeed be continued if possible, but effective treatment of her infection would be the immediate priority. Mastitis is not necessarily self-limiting and mammography is not normally indicated.
Which of the following is the priority nursing intervention in helping a client expectorate thick lung secretions?
Increase fluid intake to 3 L/day if tolerated
Although several interventions may help the client expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the client can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the client to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed.
Which of the following tasks can the nurse delegate to an unregulated care provider (UCP) in the care of a client who has recently undergone prostatectomy?
Performing cleansing of the meatus and perineal region
Performing perineal care is an appropriate task for delegation. Selecting analgesia, irrigating the client’s catheter, and assessing his incision are not appropriate for skills or tasks for unlicensed personnel.
The nurse asks a client scheduled for colectomy to sign the operative consent as directed in the health care provider’s preoperative orders. The client states that the health care provider has not really explained well what is involved in the surgical procedure. Which of the following is the best action by the nurse?
Delay the client’s signature on the consent and notify the health care provider about the conversation with the client.
The client should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the client. The nurse should notify the health care provider, who has the responsibility for obtaining consent.
The nurse is caring for a client receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this client is at risk for tumour lysis syndrome (TLS) and will monitor the client closely for which of the following abnormalities associated with this oncological emergency?
Hypocalcemia
TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal failure. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.