The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?
Fluid accumulation under the arm.
Drainage from the area.
Reddened area around the breast.
Enlargement of the arm or hand.
The Correct Answer is A
Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.
Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.
Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.
Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
sigmoid. A double-barrel colostomy involves surgically creating two separate stomas from the colon, with the proximal stoma discharging stool and the distal stoma discharging mucus. This type of colostomy is typically performed in the sigmoid colon, which is the S-shaped segment of the large intestine located just before the rectum.
Choice A, ascending, is not the correct answer because an ascending colostomy is created in the ascending colon, which is located on the right side of the abdomen.
Choice B, descending, is not the correct answer because a descending colostomy is created in the descending colon, which is located on the left side of the abdomen.
Choice C, transverse, is not the correct answer because a transverse colostomy is created in the transverse colon, which is located across the upper abdomen.
Correct Answer is A
Explanation
Exposing the affected area to air. Exposing the affected area to air is appropriate because it allows the skin to breathe and reduces the risk of skin breakdown. The client should be instructed to change the pad frequently and wash the perineal area with mild soap and water.
Option B, avoiding the application of moisture sealant, may increase the risk of skin breakdown.
Option C, avoiding using an electric room deodorizer, is not related to the situation.
Option D, using scented sprays or perfumes, may cause skin irritation.
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