A nurse is caring for an 84-year-old male client who is at home on hospice care.

At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Choice A rationale

A family history of breast cancer, particularly in first-degree relatives, significantly increases an individual's risk due to the potential inheritance of genetic mutations, such as BRCA1 and BRCA2. These genes play crucial roles in DNA repair, and their mutation impairs this function, leading to uncontrolled cell proliferation and increased cancer susceptibility.

Choice B rationale

Increased alcohol consumption is a known risk factor for breast cancer. Alcohol metabolism produces acetaldehyde, a genotoxic compound, and also elevates estrogen levels. Both mechanisms contribute to cellular DNA damage and promote cell proliferation, thereby increasing the risk of malignant transformation in mammary tissue.

Choice C rationale

Breastfeeding is scientifically recognized as a protective factor against breast cancer. The physiological changes during lactation, including terminal differentiation of mammary epithelial cells and reduced lifetime exposure to estrogen, decrease the risk of malignant transformation. Longer durations of breastfeeding correlate with greater risk reduction.

Choice D rationale

Early menarche, defined as the onset of menstruation before age 12, increases a woman's lifetime exposure to estrogen. Estrogen is a key hormone in breast tissue development and proliferation. Prolonged exposure to higher estrogen levels throughout reproductive life is associated with an elevated risk of developing breast cancer due to increased cell division.

Choice E rationale

The use of oral contraceptives has been linked to a slightly increased risk of breast cancer, particularly current or recent use. These contraceptives contain exogenous hormones, primarily estrogen and progestin, which can influence mammary gland proliferation. The risk generally decreases over time after discontinuation of oral contraceptive use.

Choice F rationale

Late menopause, occurring after age 55, extends the duration of a woman's exposure to endogenous estrogen and progesterone. These hormones stimulate breast cell growth and division. A longer period of ovarian hormone activity means more cumulative cell divisions and greater opportunity for genetic mutations, thus increasing breast cancer risk.

Choice A rationale: Initiating anticoagulant therapy with heparin is the priority after confirming or strongly suspecting a pulmonary embolism (PE). The elevated D-dimer (>0.4 mcg/mL; client’s = 1.0 mcg/mL), signs of deep vein thrombosis (calf swelling, tenderness), sudden dyspnea, and chest pain with hypoxia (O2 sat 90%) all support PE. Heparin prevents further clot propagation and reduces risk of additional emboli reaching the pulmonary circulation. Early anticoagulation significantly reduces mortality and prevents long-term complications like pulmonary hypertension.

Choice B rationale: Administering oral analgesics does not address the underlying cause of the client’s symptoms, which is likely thromboembolism. Pain in this case is secondary to inflammation and ischemia related to embolism. While symptom relief is important, masking pain without addressing perfusion issues delays definitive care. Also, oral administration may be inappropriate in hemodynamically unstable or hypoxic patients due to risk of aspiration or delayed onset. This action is supportive, not emergent, and should not precede anticoagulation.

Choice C rationale: A chest X-ray may help rule out differential diagnoses like pneumonia or pneumothorax, but it is often nonspecific in pulmonary embolism. Typical findings such as atelectasis or pleural effusion lack sensitivity and may delay more appropriate imaging such as CT pulmonary angiography. Furthermore, the patient is symptomatic and hypoxic, requiring immediate stabilization and anticoagulation, not diagnostic delay. Chest X-ray may be useful later but is not prioritized before life-saving interventions like anticoagulation.

Choice D rationale: Increasing oxygen flow rate may temporarily improve oxygen saturation, but it does not address the embolic cause of the hypoxia. Pulmonary embolism leads to a ventilation-perfusion mismatch that oxygen alone cannot correct. Oxygen supplementation is supportive and should be continued, but anticoagulation directly targets the pathophysiology. Treating only the symptom (hypoxia) without preventing further thrombus migration risks clinical deterioration. Therefore, this is a secondary rather than a primary action.