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Hesi Breast Cancer case study answers here

Uploaded: 2 years ago
Contributor: mgfsu
Category: Medicine
Type: Lecture Notes
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Filename:   hesicasestudybreastcancer.docx (33.01 kB)
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1.ID:What is the best response by the nurse? "If you take hormone replacement therapy (HRT), you should perform BSE every week."Although some forms of HRT place women at higher risk for breast cancer, weekly BSE is not necessary. "Since you have had a hysterectomy, performing BSE twice a year is adequate."A hysterectomy does not reduce the risk for breast cancer. "Follow the same timing cycle you used when you had regular menstrual periods."Ease in keeping track of a schedule is important to improve compliance. However, this routine is not the easiest to remember. "Select whatever day you can best remember to perform BSE consistently every month." CorrectWhatever day is best for Sandra will improve compliance and be easiest for her to remember. Suggesting the first day of the month is one easy approach.CorrectAwarded 1.0 points out of 1.0 possible points.Sandra demonstrates BSE technique for the nurse using a practice model. She uses her fingerpads and states that when lying down, her arm should be relaxed at her side.Awarded points out of 0.0 possible points.2.ID:What instructions should the nurse provide? "You have demonstrated BSE successfully; practice this every month."Sandra's technique was only partially correct. She needs further teaching. "Use your fingertips rather than the pads of your fingers."Use of the fingerpads is the correct technique, because the pads are more sensitive than the fingertips. "When lying down, your arm should be positioned over your head." CorrectPlacing the arm over the head when lying down helps spread the breast tissue over the chest wall, making palpation more effective. Sandra did correctly use her fingerpads, which are more sensitive than the fingertips."Place your hand on your hip and flex your arm while lying down."This can be done while Sandra is standing to assess for changes in the shape of the breasts.CorrectAwarded 1.0 points out of 1.0 possible points.Another woman in the class said she had heard that clinical breast examination (CBE) is better than breast self-examination (BSE).Awarded points out of 0.0 possible points.3.ID:How should the nurse respond? "The combination of yearly CBE and monthly BSE is the best approach for early detection." CorrectThe American Cancer Society currently recommends both monthly BSE and annual CBE for asymptomatic women over age 40."If your doctor is doing CBE every year, doing BSE monthly isn't really necessary to detect cancer."The American Cancer Society currently recommends both monthly BSE and annual CBE for asymptomatic women over age 40. "Doing BSE every month offers a better chance of finding a lump early than doing CBE once a year."The American Cancer Society currently recommends both monthly BSE and annual CBE for asymptomatic women over age 40. "CBE is only performed after a problem is detected during BSE, so it is very important to perform BSE."CBE should be performed on a regular basis. The American Cancer Society currently recommends annual CBE for asymptomatic women over age 40.CorrectAwarded 1.0 points out of 1.0 possible points.4.ID:What intervention should the nurse implement first? Teach Barb that even women with no identified risk factors are at risk. CorrectThe single most important risk factor for breast cancer is being an older female. Teaching Barb about the need for routine BSE and mammograms is the nurse's highest priority, so the client will be able to make an informed decision about screening. Reassure Barb that her father's sister is not a first-degree relative.This is correct and important information, but it is not the highest priority action. Schedule Barb for a mammogram as soon as it can be arranged.This is important, but it is not the highest priority action. Show Barb the equipment used to perform a mammogram.This is important, but it is not the highest priority action.CorrectAwarded 1.0 points out of 1.0 possible points.Barb states she will schedule a mammogram, but asks the nurse if the x-ray is painful.Awarded points out of 0.0 possible points.5.ID: "The pain of the procedure is worth the benefit you will gain."This does not directly answer Barb's question, and it is judgmental. "Tell me what your concerns are related to experiencing pain."Barb's question is clear and should be answered directly. Using an open-ended statement is not the best method of communication. "X-ray procedures do not typically cause any sort of discomfort."While most routine x-ray procedures do not cause discomfort, mammograms do apply pressure to the breast tissue, which is often uncomfortable. "You may experience some discomfort, but only for a few minutes." CorrectThis provides accurate information and answers Barb's question. CorrectAwarded 1.0 points out of 1.0 possible points.6.ID:What is the best response by the nurse? "I will notify the health care provider that you would like the test repeated."This response may encourage Sandra's continued denial of her diagnosis, and it is not the best therapeutic response. "It's hard to believe that this is happening, isn't it?" CorrectThis response acknowledges the overwhelming situation Sandra is facing, yet does not encourage her denial. It is open-ended, leaving Sandra the opportunity to further share her feelings. "Tell me why you feel an error was made on the test." IncorrectThis response may encourage Sandra's continued denial of her diagnosis, and it is not the best therapeutic response. "Right now you are feeling denial. It takes time to accept this."This response labels Sandra's feelings, and it does not encourage further verbalization.IncorrectAwarded 0.0 points out of 1.0 possible points.Sandra goes on to say, "I can control this. I will start exercising and change my eating habits. That will take care of it."Awarded points out of 0.0 possible points.7.ID:How should the nurse respond? "You need to recognize that you have cancer that needs surgery." IncorrectThis statement gives advice to Sandra, rather than allowing her to express her feelings. "Tell me what kind of diet changes you are planning to make."This statement contributes to Sandra's denial of the situation. "Have you considered vitamin and herbal alternatives?"This statement contributes to Sandra's denial of the situation. "Are you saying that you do not want to have surgery?" CorrectThis statement will help Sandra clarify her thinking and verbalize her feelings.IncorrectAwarded 0.0 points out of 1.0 possible points.8.ID:Which nursing diagnosis should be reflected in Sandra's plan of care? Prolonged grieving.There is no evidence of a prolonged grief response. Dysfunctional grieving. IncorrectThere is no evidence of a dysfunctional pattern or degree of grief. Anticipatory grieving. CorrectSandra's denial is normal in anticipation of the loss of her breast. The nurse should offer support as Sandra grieves in anticipation of this loss.Lack of grieving.Sandra's grief response of denial is normal. Also, "lack of grieving" is not a NANDA-approved diagnosis statement.IncorrectAwarded 0.0 points out of 1.0 possible points.9.ID:What is the best response by the nurse? "Since it was a small snack that won't be harmful, I won't record it in the chart."This may result in harm to the client and reflects unsafe nursing practice. "I know how important this is to you, so we'll keep this between us."This may result in harm to the client and reflects unsafe nursing practice. "To ensure your safety, I need to notify the surgeon of the snack you ate." CorrectThe surgeon and/or anesthesia personnel need this information to determine the safest schedule for the surgery. "You should not have eaten the snack. Any intake means a delay in surgery."This may or may not be correct and reflects badgering the client, rather than acting as a client advocate and ensuring safe practice.CorrectAwarded 1.0 points out of 1.0 possible points.10.ID:Which ethical principle has the greatest weight in the nurse's decision to inform Sandra's surgeon about the snack? Justice.Justice refers to fair and equal treatment and does not have the greatest weight in this decision. Nonmaleficence. CorrectThis ethical principle has the greatest weight in this situation, because the wrong decision by the nurse could cause harm to Sandra. Autonomy.Autonomy is the right to make one's own choices. In this situation, Sandra made the choice to have a snack and to tell the nurse, but the nurse must make the decision regarding the nursing action in response to that information. Confidentiality.Confidentiality is the client's right to privacy. The nurse should not guarantee Sandra that all information will be held in confidence, since withholding the information could cause harm to the client.CorrectAwarded 1.0 points out of 1.0 possible points.The nurse confirms that Sandra has signed the informed consent for surgery, but learns that Sandra does not understand the procedure for breast reconstruction that is to be performed.Awarded points out of 0.0 possible points.11.ID:What action should the nurse implement? Describe the procedure to Sandra using simple language and drawings.The surgeon has the responsibility to inform the client adequately about the procedure. Offer reassurance and support, since the consent is already signed.The nurse should take further action if the client expresses a lack of understanding about the scheduled procedure, even if the consent is already signed. Affirm that Sandra has made a good choice in having immediate reconstruction.The nurse should take further action if the client expresses a lack of understanding about the scheduled procedure, even if the consent is already signed. Notify the surgeon that further explanation of the procedure is necessary. CorrectThe surgeon has the responsibility to inform the client adequately about the procedure, and should provide any further explanation, even if consent has already been obtained.CorrectAwarded 1.0 points out of 1.0 possible points.12.ID:Which nursing actions have the highest priority in the initial postoperative period? (Select all that apply.) Review hand and wrist exercises with Sandra.This is an important postoperative nursing action, but it does not have the highest priority during immediate postoperative management in the PACU. Observe the Jackson-Pratt drainage device. CorrectDuring the initial postoperative period, one of the nurse's highest priorities is to ensure that homeostasis is maintained by monitoring vital signs and assessing for postoperative bleeding. After determining Sandra is physiologically stable, the nurse can initiate pain management, privacy, and postoperative teaching. Administer a PRN dose of prescribed analgesic. CorrectIf Sandra’s pain is under control, she will be able to move and breathe more efficiently. This important postoperative nursing action also has priority during the initial PACU period. Provide privacy for Sandra and her husband.This is an important postoperative nursing action, but it does not have the highest priority over the physiological interventions. Monitor vital signs and pulse oximetry. CorrectDuring the initial postoperative period, one of the nurse’s highest priorities is to monitor vital signs and oxygen levels to determine respiratory and cardiac homeostasis.CorrectAwarded 1.0002 points out of 1.0002 possible points.After Sandra is awake and stable, she is moved from the PACU to the regular post-op unit. The nurse observes Sandra performing wrist flexion and extension exercises 4 hours after surgery.Awarded points out of 0.0 possible points.13.ID:What action should the nurse take? Encourage Sandra to continue performing these exercises. CorrectThis is an appropriate exercise following surgery. Sandra can begin finger and wrist flexion and extension immediately after surgery and progress to flexion of the elbow. Arm range of motion exercises are typically started after the drain is removed, or about 1 week after surgery. It is also important that Sandra's arm be elevated on a pillow following surgery to promote fluid return and prevent lymphedema.Advise Sandra to exercise only her fingers for the first 24 hours.Sandra can begin more than just finger exercises at this time. Instruct Sandra to avoid any exercises until the next morning.Sandra can begin finger and wrist flexion and extension exercises immediately after surgery. Remind Sandra that she can also begin arm range of motion (ROM) activities. IncorrectArm exercises are typically started after the drain is removed, or about 1 week after surgery.IncorrectAwarded 0.0 points out of 1.0 possible points.14.ID:What action should the nurse implement first? Assign the UAP to place a sign over the bed to avoid BPs on the operative side. IncorrectThis is an important action, but another action has a higher priority. Tell the GN that it is a nursing responsibility to supervise the UAP correctly.This action should be performed, but other actions have a higher priority. Advise the UAP to immediately stop and obtain a larger cuff so the BP reading can be taken in the leg. CorrectThe priority is to ensure that postoperative vital signs are monitored correctly and in a timely manner that is not harmful to the client. The BP should not be taken in the operative arm, so the UAP should first be instructed to stop and obtain a cuff large enough to accurately measure the BP in the leg. The nurse or UAP should also place a sign over the bed to prevent BPs and venipunctures from being obtained on the operative side. Once safe care is ensured, the nurse can discuss the situation with the GN and UAP privately. Leave the room with the GN and UAP to discuss the situation in the conference room.This should be done, since unsafe practice was being performed. However, other actions have a higher priority.IncorrectAwarded 0.0 points out of 1.0 possible points.The nurse is discussing the situation with the GN and UAP.Awarded points out of 0.0 possible points.15.ID:What should the nurse emphasize in the discussion? Assessment of postoperative vital signs should not be assigned to a UAP.A UAP is qualified to obtain vital signs, although the analysis of the vital signs is the responsibility of the nurse. As the supervising nurse, the GN is fully responsible for the incorrect action taken.The GN is responsible to supervise the UAP to ensure safe practice. However, the UAP is also responsible for his/her own actions. Both the GN and UAP are at fault for the incorrect action of the UAP. CorrectThe UAP is responsible to safely and correctly perform those skills for which he/she is certified. The GN is responsible for supervising the UAP's actions and providing accurate direction.The UAP is certified to take vital signs and is fully responsible for the action taken. IncorrectThe UAP is responsible for his/her actions. However, the supervising nurse is also responsible to provide accurate directions and ensure safe practice by the UAP.IncorrectAwarded 0.0 points out of 1.0 possible points.16.ID:What action should the nurse take first? Review the meaning of negative estrogen receptor sites with Sandra.Client teaching may be provided, but another action has priority. Contact Sandra's health care provider to confirm the test results.This may become necessary, but another action has priority. Review the operative report and tissue analysis in Sandra's medical record.Sandra's understanding is incorrect, but another action has priority. Ask Sandra to clarify how she learned this information so that a plan for further teaching can be developed. CorrectSince Sandra's understanding is incorrect, the nurse should first determine how Sandra learned the information so that a plan for further teaching can be developed.CorrectAwarded 1.0 points out of 1.0 possible points.Since Sandra's tumor is estrogen-receptor negative, she is not a candidate for hormonal therapy. Tamoxifen (Nolvadex) is an antiestrogen drug often used to prevent or treat recurrent breast cancer. Sandra states a friend of hers took this drug and has had no recurrence of her breast cancer. The nurse asks Sandra if her friend experienced any problems when taking tamoxifen.Awarded points out of 0.0 possible points.17.ID:Which complication is most often associated with tamoxifen? Ototoxicity.This is not a complication commonly associated with tamoxifen. Blood clots. CorrectTamoxifen increases the risk for blood clots and for endometrial cancer. Hypertension.This is not a complication commonly associated with tamoxifen. Anemia. IncorrectThis is not a complication commonly associated with tamoxifen. However, thrombocytopenia and transient leukopenia may occur.IncorrectAwarded 0.0 points out of 1.0 possible points.Sandra is disappointed to learn that she will not benefit from hormonal therapy, but states her friend did indicate that taking the medication was "like experiencing menopause."Awarded points out of 0.0 possible points.18.ID:How should the nurse respond? "The medication decreases estrogen levels, which is what also causes the symptoms of menopause." CorrectTamoxifen is an antiestrogen agent and may cause the same symptoms of decreased estrogen that occur during menopause, such as hot flashes, dry skin, nausea, and menstrual irregularities. "With the medication, the effects of estrogen are enhanced, which is what women in menopause experience."Estrogen levels are not enhanced with the use of tamoxifen or during menopause. "The medication was probably not the cause of her symptoms. They were probably related to the cancer." IncorrectMenopausal-like symptoms are common side effects of tamoxifen, but they are not expected side effects of breast cancer. "If she also had breast surgery, she probably would have those symptoms even without the medication."Menopausal-like symptoms are common side effects of tamoxifen, but they are not expected side effects after a mastectomy.IncorrectAwarded 0.0 points out of 1.0 possible points.19.ID:What side effects are most often associated with antineoplastic chemotherapy used to treat breast neoplasms should be included in this discussion? (Select all that apply.) Loss of vision. IncorrectThis is not a common side effect of antineoplastic agents. Diarrhea. CorrectGI side effects are common with the use of antineoplastic agents. Seizures.This is not a common side effect of antineoplastic agents. Tinnitus. IncorrectThis is not a common side effect of antineoplastic agents. Alopecia. CorrectAlopecia, or hair loss, is a common side effect of antineoplastic agents.IncorrectAwarded 0.0 points out of 1.0 possible points.A multi-lumen central line has been inserted, and the nurse is preparing to administer a dose of chemotherapy through the central line by first flushing the IV lumens. The nurse notes that two of the four lumens do not flush easily.Awarded points out of 0.0 possible points.20.ID:What intervention is appropriate for the nurse to implement? Hold the scheduled dose of chemotherapy until a chest x-ray is done.A chest x-ray is not warranted unless the nurse suspects that the central line has become displaced. Ask Sandra to perform the Valsalva maneuver while flushing the lines.A Valsalva maneuver will not alter a clotted central line. Notify the health care provider that the central line is no longer functional.Since there are still two functional lumens, the health care provider does not need to be notified that the central line is not functional. Label the two lumens as non-functional, and use one of the remaining lumens. CorrectMulti-lumen catheters are designed so that each lumen can be used as a separate IV line. The obstructed lines should be labeled and no longer used. A chest x-ray is not warranted unless the nurse suspects that the central line has become displaced. A Valsalva maneuver will not alter a clotted central line. Since there are still two functional lumens, the health care provider does not need to be notified that the central line is not functional. CorrectAwarded 1.0 points out of 1.0 possible points.The nurse is aware that treatment with antineoplastic chemotherapeutic agents can cause immunosuppression, which predisposes the client to infection.Awarded points out of 0.0 possible points.21.ID:Which assessment finding would cause the nurse to suspect that an immunosuppressed client has an infection? Tingling in fingers.This is an adverse effect of some chemotherapy medications but it is not an indication of infection. Nausea.Nausea is an adverse effect of some chemotherapy medications but it is not generally an indication of infection. Oral temperature of 99.5° F. CorrectAn immunosuppressed individual may only develop a low-grade fever in response to infection. The immunosuppressed client should report a low-grade fever, a persistent cough, any unusual drainage, or any other symptoms of infection to the health care provider immediately. Epistaxis.Epistaxis, or nosebleed, may occur as the result of chemotherapy-induced thrombocytopenia, but it is not an indication of infection.CorrectAwarded 1.0 points out of 1.0 possible points.22.ID:Which nursing diagnosis has the highest priority when planning care for Sandra? Self-care deficit.This problem is caused by restricted motion of the affected arm, but it is not the highest priority. Impaired mobility.This problem is caused by restricted mobility of the affected arm and it is not the highest priority. Acute pain.While the arm tenderness needs appropriate nursing care, this problem is not the highest priority. Altered tissue perfusion. CorrectImpaired tissue perfusion caused by increased lymphedema in the affected arm is the highest priority. The nurse should ensure that no tissue damage has occurred.CorrectAwarded 1.0 points out of 1.0 possible points.23.IDWhich nursing care measure(s) will be most beneficial in the management of Sandra's highest priority problem? (Select all that apply.) Place Sandra in a semi-Fowler's position.This will probably be the position of comfort post-operatively, but it is not the most beneficial action in the management of Sandra’s highest priority problem. Apply a sequential compression device. CorrectLymphedema is managed with arm elevation and the use of an arm, sleeve, or sequential compression device to promote fluid return. Review hand exercises Sandra can perform. IncorrectThis will be beneficial to maintain range of motion and improve fluid return, but it is not the most beneficial action. Provide high protein snacks between meals. IncorrectThis will help promote wound healing, but it is not the most beneficial action. Elevate the affected arm. CorrectLymphedema is managed with arm elevation and the use of an arm, sleeve, or sequential compression device to promote fluid return.IncorrectAwarded 0.0 points out of 1.0 possible points.Sandra's prescriptions include vancomycin (Vancocin) IV 1 g every 12 hours, obtain peak and trough levels, and acetaminophen 500 mg PO for fever >100° F.Awarded points out of 0.0 possible points.24.IWhen is the best time to obtain the vancomycin serum trough level? When all the prescribed doses have been administered.This will not provide ongoing information to ensure safe medication dosing during treatment. Thirty minutes after the administration of the most recent dose of the drug.This is the correct time to obtain the serum peak level. Fifteen minutes prior to administration of the next dose of the drug. CorrectThe trough level should reflect the lowest amount of the drug circulating in the client's system. This provides useful information about the dosage of the medication to reduce the risk for drug toxicity. Prior to initiating the first dose of the prescription.This will not provide any useful information, since there will be no medication in the client's system.CorrectAwarded 1.0 points out of 1.0 possible points.25.It is time for Sandra’s vancomycin (Vancocin). The vancomycin (Vancocin) IV 1 g is in a 250 mL bag of 0.9% normal saline to be delivered in 1 hour. The IV tubing set is 15 drops/mL. How many drops per minute would the nurse set on the IV pump? (Enter the numerical value only. If rounding is necessary, round to the whole number.)CorrectCorrect Responses63250 x 15/60 minutes = 62.5 rounded to 63 drops/minute.Awarded 1.0 points out of 1.0 possible points.After receiving vancomycin for 7 days, Sandra complains that her mouth is painful when she swallows. When assessing her mouth, the nurse visualizes white, patchy lesions.Awarded points out of 0.0 possible points.26.What is the most probable cause of this finding? Candida superinfection. CorrectA superinfection is a secondary infection that occurs during antibiotic therapy when normal microbial flora are disrupted. Fungal infections, such as Candida, are commonly occurring superinfections. White, patchy lesions are typical of Candida and are treated with nystatin. Non-healing skin lesion.This is unlikely to be the cause. Anemia.This is unlikely to be the cause. Metastasis of the cancer.This is unlikely to be the cause.CorrectAwarded 1.0 points out of 1.0 possible poinWhich client's history indicates the person at highest risk for breast cancer? A 35-year-old, unemployed, obese woman, who has five children and two grandchildren.Obesity may be related to increased breast cancer risk, but another client is at higher risk. A 40-year-old female attorney with delayed pubertal development, including starting her period at age 17.Menarche beginning prior to the age of 12 is considered a risk factor, rather than delayed menarche. A 45-year-old female nurse who is starting to experience menopausal symptoms.Late-onset menopause (after age 55) is considered a risk factor. A 65-year-old woman, who is a retired teacher and who never married or had children. CorrectRisk factors include being female, postmenopausal, and nulliparity. The incidence of breast cancer increases significantly for women over the age of 60. Early menarche (age 12 or younger), late onset of menopause (age 55 or older), and nulliparity or the first full-term pregnancy after age 30 are all risk factors.CorrectAwarded 1.0 points out of 1.0 possible points.Sandra talks about her own risk factors.Awarded points out of 0.0 possible points.28.IThe development of breast cancer by which family member indicates Sandra's increased risk? Maternal aunt.Increased risk occurs primarily when a first-degree relative has breast cancer. Younger sister. CorrectIncreased risk occurs primarily when a first-degree relative, such as a mother, sister, or daughter has had breast cancer, especially if the family member was premenopausal or had bilateral disease.Mother-in-law.Increased risk occurs primarily when a first-degree relative has breast cancer. Older female cousin.Increased risk occurs primarily when a first-degree relative has breast cancer.CorrectAwarded 1.0 points out of 1.0 possible points.29.Which symptom of breast cancer does this describe? Alteration in the shape of the breast.This is a finding that may indicate breast cancer, but it is not the change referred to as peau d'orange. Change in the color of the skin. IncorrectThis is a finding that may indicate breast cancer, but it is not the change referred to as peau d'orange. Pain and ulceration of the skin.This is a finding that may indicate breast cancer, but it is not the change referred to as peau d'orange. Unusual skin texture. CorrectPeau d'orange is a dimpling or "orange peel" appearance of the skin that may indicate advanced breast cancer. IncorrectAwarded 0.0 points out of 1.0 possible points.Sandra shares with the group that a lump she felt during self breast exam was the only symptom she had.Awarded points out of 0.0 possible points.30.Which description of a breast lump is most typical of breast cancer? Hard, irregular, and does not move freely. CorrectThe characteristic description of a cancerous breast mass that is palpable includes hard, irregular shape, poorly delineated, non-tender, and non-mobile. Most palpable masses occur in the upper outer quadrant of the breast. Soft and mashes down easily when touched.This is not the characteristic description of a palpable, cancerous breast mass. Raised, warm, and tender when palpated.This is not the characteristic description of a palpable, cancerous breast mass. Moves easily under the skin with very defined borders.This is not the characteristic description of a palpable, cancerous breast mass.CorrectAwarded 1.0 points out of 1.0 possible points.s.

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