Chapter 65: Concepts of Care for Patients
with Breast Disorders
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A younger woman from an unfamiliar culture is at high risk for breast cancer and is
considering a prophylactic mastectomy and oophorectomy. What action by the nurse
is most appropriate?
a. Discourage this surgery since the woman is still of childbearing age.
b. Reassure the client that reconstructive surgery is as easy as breast
augmentation.
c. Inform the client that this surgery removes all mammary tissue and cancer risk.
d. Offer to include support people, such as the male partner, in the decision
making.
ANS: D
The cultural aspects of decision making need to be considered. In some cultures, the
man often makes the decisions for care of the female. The woman may want to make
the decision with other support people or by herself. The nurse must maintain
sensitivity to cultural, religious, and personal beliefs when it comes to this personal
decision. Women with a high risk for breast cancer can consider prophylactic surgery.
If reconstructive surgery is considered, the procedure is more complex and will have
more complications compared to a breast augmentation. There is a small risk that
breast cancer can still develop in the remaining mammary tissue.
DIF: Applying TOP: Integrated Process: Caring KEY: Breast
cancer, Culture MSC: Client Needs Category: Psychosocial Integrity
, 2. A client has just returned from a right radical mastectomy. Which action by the
assistive personnel (AP) would require the nurse consider to intervene?
a. Checking the amount of urine in the catheter collection bag
b. Elevating the right arm on a pillow
c. Taking the blood pressure on the right arm
d. Encouraging the client to squeeze a rolled washcloth
ANS: C
Health care professionals need to avoid the arm on the side of the surgery for blood
pressure measurement, injections, or blood draws. Since lymph nodes are removed,
lymph drainage would be compromised. The pressure from the blood pressure cuff
could promote swelling. Infection could occur with injections and blood draws.
Checking urine output, elevation of the affected arm on a pillow, and encouraging
beginning exercises are all safe postoperative interventions.
DIF: Applying TOP: Integrated Process: Nursing Process: Analysis
KEY: Breast cancer, Postoperative care MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
3. A client is discharged to home after a modified radical mastectomy with two drainage
tubes. Which statement by the client would indicate that further teaching is needed?
a. “I am glad that these tubes will fall out at home when I finally shower.”
b. “I should measure the drainage each day to make sure it is less than an ounce
(30 mL).”
c. “I should be careful how I lie in bed so that I will not kink the tubing.”
d. “If there is a foul odor from the drainage, I will contact my primary health care
provider.”
ANS: A
The drainage tubes (such as a Jackson–Pratt drain) lie just under the skin but need to
be removed by the health care professional in about 1 to 3 weeks at an office visit.
Drainage should be less than 30 mL for three consecutive days. The client should be
with Breast Disorders
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A younger woman from an unfamiliar culture is at high risk for breast cancer and is
considering a prophylactic mastectomy and oophorectomy. What action by the nurse
is most appropriate?
a. Discourage this surgery since the woman is still of childbearing age.
b. Reassure the client that reconstructive surgery is as easy as breast
augmentation.
c. Inform the client that this surgery removes all mammary tissue and cancer risk.
d. Offer to include support people, such as the male partner, in the decision
making.
ANS: D
The cultural aspects of decision making need to be considered. In some cultures, the
man often makes the decisions for care of the female. The woman may want to make
the decision with other support people or by herself. The nurse must maintain
sensitivity to cultural, religious, and personal beliefs when it comes to this personal
decision. Women with a high risk for breast cancer can consider prophylactic surgery.
If reconstructive surgery is considered, the procedure is more complex and will have
more complications compared to a breast augmentation. There is a small risk that
breast cancer can still develop in the remaining mammary tissue.
DIF: Applying TOP: Integrated Process: Caring KEY: Breast
cancer, Culture MSC: Client Needs Category: Psychosocial Integrity
, 2. A client has just returned from a right radical mastectomy. Which action by the
assistive personnel (AP) would require the nurse consider to intervene?
a. Checking the amount of urine in the catheter collection bag
b. Elevating the right arm on a pillow
c. Taking the blood pressure on the right arm
d. Encouraging the client to squeeze a rolled washcloth
ANS: C
Health care professionals need to avoid the arm on the side of the surgery for blood
pressure measurement, injections, or blood draws. Since lymph nodes are removed,
lymph drainage would be compromised. The pressure from the blood pressure cuff
could promote swelling. Infection could occur with injections and blood draws.
Checking urine output, elevation of the affected arm on a pillow, and encouraging
beginning exercises are all safe postoperative interventions.
DIF: Applying TOP: Integrated Process: Nursing Process: Analysis
KEY: Breast cancer, Postoperative care MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
3. A client is discharged to home after a modified radical mastectomy with two drainage
tubes. Which statement by the client would indicate that further teaching is needed?
a. “I am glad that these tubes will fall out at home when I finally shower.”
b. “I should measure the drainage each day to make sure it is less than an ounce
(30 mL).”
c. “I should be careful how I lie in bed so that I will not kink the tubing.”
d. “If there is a foul odor from the drainage, I will contact my primary health care
provider.”
ANS: A
The drainage tubes (such as a Jackson–Pratt drain) lie just under the skin but need to
be removed by the health care professional in about 1 to 3 weeks at an office visit.
Drainage should be less than 30 mL for three consecutive days. The client should be
