A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?

Fluid balance

Body image

Urinary elimination

Activity

Answer and Explanation

The Correct Answer is B

Choice A: Fluid balance is not the most likely priority because it is not directly affected by the mastectomy. Fluid balance is the state of equilibrium between the intake and output of fluids in the body. It can be influenced by various factors such as hydration, nutrition, medication, or illness. It can be monitored by measuring vital signs, weight, urine output, or laboratory values. Fluid balance is important for maintaining homeostasis and preventing dehydration or edema, but it is not a specific concern for a client undergoing a mastectomy.

Choice B: Body image is the most likely priority because it is directly affected by the mastectomy. Body image is the perception and attitude that one has toward one's own physical appearance and function. It can be influenced by various factors such as culture, media, self-esteem, or feedback from others. It can be assessed by observing verbal and nonverbal cues, asking open-ended questions, or using standardized tools. Body image is a major psychosocial issue for a client undergoing a mastectomy, as it can affect one's sense of identity, femininity, sexuality, or attractiveness. The nurse should address body image by providing information, support, and referral to appropriate resources.

Choice C: Urinary elimination is not the most likely priority because it is not directly affected by the mastectomy. Urinary elimination is the process of expelling urine from the bladder through the urethra. It can be influenced by various factors such as fluid intake, kidney function, medication, or infection. It can be assessed by measuring urine volume, color, odor, or specific gravity. Urinary elimination is important for maintaining fluid balance and preventing urinary tract infection or retention, but it is not a specific concern for a client undergoing a mastectomy.

Choice D: Activity is not the most likely priority because it is not directly affected by the mastectomy. Activity is the level of physical movement and exercise that one engages in on a daily basis. It can be influenced by various factors such as age, health status, motivation, or environment. It can be assessed by observing mobility, endurance, strength, or coordination. Activity is important for maintaining muscle tone, joint range of motion, circulation, or metabolism, but it is not a specific concern for a client undergoing a mastectomy.

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Correct Answer is D

Explanation

Choice A: Menstrual is not the correct answer because it is the phase when estrogen levels are lowest. The menstrual phase occurs when the endometrium (the lining of the uterus) is shed along with blood and mucus through the vagina.

Choice B: Ischemic is not the correct answer because it is the phase when estrogen levels are decreasing. The ischemic phase occurs when the blood supply to the endometrium is reduced due to vasoconstriction (narrowing of blood vessels). This phase prepares the endometrium for shedding if fertilization does not occur.

Choice C: Secretory is not the correct answer because it is the phase when progesterone levels are highest. The secretory phase occurs when the endometrium becomes thick and spongy due to increased secretion of mucus and glycogen (a form of sugar). This phase provides a suitable environment for implantation if fertilization occurs.

Choice D: Proliferative is the correct answer because it is the phase when estrogen levels are highest. The proliferative phase occurs when the endometrium regenerates and grows due to increased stimulation by estrogen. This phase prepares the endometrium for implantation if fertilization occurs.

A. Diarrhea B. Anorexia C. Fatigue D. Alopecia

Correct Answer is C

Explanation

Choice A: Diarrhea is not the correct answer because it is not a common adverse effect of radiation treatment for breast cancer. Diarrhea is a condition that causes loose, watery, or frequent stools. It can be caused by various factors such as infection, medication, or food intolerance. It is more likely to occur as an adverse effect of radiation treatment for cancers that affect the digestive system, such as colorectal or stomach cancer.

Choice B: Anorexia is not the correct answer because it is not a common adverse effect of radiation treatment for breast cancer. Anorexia is a condition that causes loss of appetite or interest in food. It can be caused by various factors such as depression, stress, or nausea. It is more likely to occur as an adverse effect of chemotherapy or other systemic treatments for cancer that affect the whole body.

Choice C: Fatigue is the correct answer because it is a common adverse effect of radiation treatment for breast cancer. Fatigue is a condition that causes extreme tiredness or exhaustion that is not relieved by rest or sleep. It can be caused by various factors such as anemia, inflammation, or pain. It is a common adverse effect of radiation treatment for any type of cancer, as radiation can damage healthy cells and tissues and affect the body's energy production.

Choice D: Alopecia is not the correct answer because it is not a common adverse effect of radiation treatment for breast cancer. Alopecia is a condition that causes hair loss or thinning on the scalp or other parts of the body. It can be caused by various factors such as genetics, hormones, or infection. It is more likely to occur as an adverse effect of chemotherapy or other systemic treatments for cancer that affect the whole body.

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A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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