In reviewing a client's medical record, the nurse notes that a female client's left breast is larger than the right and the skin on the larger breast is dimpled. The nipples of both breasts are inverted and the client reports cyclic generalized tenderness. Which finding in the client's history is indicative of breast cancer?

Rationale:

• Insert indwelling urinary catheter: Invasive procedures, including catheterization, should be avoided for at least 24 hours after fibrinolytic (Tenecteplase/tPA) administration due to the high risk of internal bleeding. If absolutely necessary, they should have been inserted before the medication was given.

• Assess family strengths and resources: Evaluating the family’s ability to assist with care is critical for discharge planning. Stroke patients often require support with ADLs and mobility, and early assessment promotes safer transitions and continuity of care.

• Perform range-of-motion exercises twice per day: To prevent contractures, joint stiffness, and muscle atrophy, passive and active range-of-motion exercises should be performed on affected limbs. Early mobility interventions reduce complications of immobility.

• Apply graduated compression stockings or SCDs: Stroke patients are at increased risk for deep vein thrombosis due to immobility. Compression devices or stockings facilitate venous return and help prevent thromboembolic events.

• Have an oral suction device available: Clients with dysphagia, decreased gag reflex, or impaired consciousness are at risk for aspiration. Having suction available ensures airway protection and prevents respiratory complications.

• Establish a nonverbal communication code system: Clients with aphasia or expressive communication deficits benefit from a nonverbal code system to express needs, which supports patient safety, reduces frustration, and facilitates care delivery.

Rationale:

• Refrain from sharing towels and razors with others: Sharing personal items can transmit bacteria that may enter broken skin and lead to future cellulitis. Educating the client to avoid sharing towels or razors reduces the risk of reinfection. This instruction focuses on preventive hygiene practices. Proper personal item hygiene is essential for clients with recurrent skin infections.

• Wash hands before and after touching open wounds including bug bites: Hand hygiene prevents the transfer of bacteria from hands to wounds, reducing the risk of infection. Teaching the client to wash hands regularly when caring for wounds helps prevent future cellulitis. This practice minimizes microbial contamination of skin breaks. It is a key preventive measure, especially in immunocompromised clients or those with diabetes.

• Eat foods which contain protein and vitamin C: Protein supports tissue repair, and vitamin C promotes collagen synthesis and immune function. Consuming adequate nutrition accelerates wound healing and strengthens the body’s ability to fight infection. This instruction directly promotes recovery from the current cellulitis episode. It enhances overall tissue regeneration and immune response.

• Complete full course of antibiotic therapy: Finishing the prescribed antibiotic regimen ensures complete eradication of the infection and prevents recurrence. Partial treatment can lead to persistent infection or resistant bacteria. Educating the client on adherence supports effective healing of the current cellulitis episode. It is crucial to reduce the risk of relapse or systemic spread.

• Shower daily with antibacterial soap: Regular cleansing with antibacterial soap removes bacteria from the skin surface and prevents colonization of new breaks in the skin. Daily hygiene reduces the likelihood of future cellulitis episodes. This preventive measure is especially important in clients with diabetes or peripheral vascular disease. It helps maintain skin integrity and minimize bacterial exposure.