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Terms in this set (15)1. A client asks the nurse, "Why do I need to examine my underarms when I perform breast self-examination?" The most appropriate response by the nurse is: a. "This is the hardest area to feel for changes." "Breast tissue extends into the axilla." Breast tissue extends superiolaterally into the axilla as the axillary tail or Tail of Spence. The axilla is not the hardest area to feel for changes. The upper outer quadrant and Tail of Spence are the more common places for breast cancer to occur in women. It is not easier to detect abnormalities in the Tail of Spence. 2. What is the nurse assessing when performing a breast assessment on a client and palpating along the inner aspect of the humerus? a. Central axillary nodes Brachial (lateral axillary) nodes Lymph nodes drain lymph from the breast and axillae and return it to the bloodstream. The lateral axillary (brachial) nodes are included in the breast assessment and are located along the inner aspect of the humerus. The central axillary nodes are located high in the axilla. The subscapular nodes are located along the inner aspect of the latissimus dorsi muscle. The pectoral nodes lie inside the pectoral fold in the axilla. 2. A teenage girl is upset because her breasts are not the same size. How should the nurse respond to this girl's concerns? a. "Your breasts really appear equal in
size." "It is normal for breast tissue development to be unequal during puberty. It will even out as you get older." Growth of the breasts is not steady or symmetrical. Reassure girls that the rate of breast tissue growth depends on changing hormone levels and is uniquely individual. Stating that the breasts look equal to the examiner is not appropriate in this situation. Telling the client not to worry is not a therapeutic communication technique. Asking whether the adolescent's mother experienced the same development is not appropriate as it is common and normal for asymmetry to be present during breast development. 3. When performing a breast examination, the nurse notes the presence of Montgomery's tubercles, soft tissue bilaterally, palpable infraclavicular lymph nodes, and slight tenderness to deep palpation bilaterally. Which of the findings does the nurse consider a deviation from normal? a. The presence of Montgomery's tubercles Palpable infraclavicular lymph nodes Normal lymph nodes should not be palpable. The presence of Montgomery's tubercles, which are tiny sebaceous glands on the areolae, is normal. The tissue of the breast should be soft. Tenderness to deep palpation is not as concerning as palpable lymph nodes in the breast assessment. 4. The nurse is planning a focused breast/axillae interview and wants to begin with a general health question. Which question would fit this criterion? a. "Has your mother or sister had breast cancer?" "Are you still menstruating?" General health questions for the breast/axillae focused interview include a description of the breasts, changes in the breasts with menstruation, and date of the last menstrual period. Family history of breast cancer is included in questions related to illness or infection. A history of breast trauma is included in questions related to symptoms. Mammogram history is included in questions related to behaviors. 5. The nurse is preparing to examine the breasts of a male client and plans to: a. position the client in the sitting position for inspection of the breasts position the client in the sitting position for inspection of the breasts •
Position the client in the sitting position for inspection of the breasts. The male client should be sitting with arms at his sides during the inspection phase of the assessment. 6. A 32-week-pregnant client is upset and is concerned about breast disease because she has been experiencing a thick, yellowish discharge coming from her breasts. How should the nurse respond to this client? a. "This is normal toward the end of pregnancy and is called colostrum." "This is normal toward the end of pregnancy and is called colostrum." A thick yellowish discharge called colostrum may be expressed from the breasts in the final weeks of pregnancy. A mammogram is not indicated in this situation since this is a normal finding. The healthcare provider does not need to be notified since this is a normal finding. The discharge is not indicative of an infection. 7. The nurse is inspecting the breasts of a female client. Which finding should trigger a prompt referral to the woman's healthcare provider? a. Left breast is slightly larger than her right Nipples are pointing in different directions Nipples should point in the same direction outward and slightly upward. A change in the direction of point of the nipple is suggestive of an abnormality. It is normal for a woman to have one breast slightly larger than the other unless this is a recent change. The presence of striae (stretch marks) is also considered within normal limits. Well-healed bilateral scarring should trigger additional questions if the nurse has not asked about breast surgery but should not trigger an immediate referral. 8. The nurse is inspecting the breasts of a female client. Which position will accentuate the presence of dimpling? The nurse asks the client to: a. sit with arms
relaxed at the sides sit with arms raised over the head Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the client's arms raised over the head, which tightens the pectoral muscles. Sitting with arms relaxed at the sides gives the examiner a general impression of the breasts. Leaning forward with arms in front of the client demonstrates whether the breasts fall freely from the chest wall. Lying flat or supine with the arm extended over the head is the position for palpation of the breast. 9. During a breast assessment, the nurse notes an inverted right nipple. The nurse knows that this is: a. always indicative of a slow-growing tumor a significant finding if it is recent Recent inversion of a nipple, a change in the direction of the nipple, or retraction of the nipple is suggestive of malignancy. Recent nipple inversion is suggestive of malignancy but not always indicative of a slow-growing tumor. This is not a normal finding in most women nor expected during pregnancy. 10. When gathering breast history information on a client, the client states that she has noticed a few drops of clear discharge from her nipples over the past few months. The nurse should: a. notify the health-care provider ask additional history questions about the discharge and medications she is currently taking Nipple discharge from medications is usually clear. This discharge is bilateral. Unilateral nipple discharge would be of more concern and perhaps be caused by an intraductal papilloma or cancer. More information needs to be obtained before determining whether to notify the healthcare provider. The nurse would document the presence of the discharge; however, more information needs to be obtained regarding the discharge. Referral for a mammogram is not indicated at this time. 11. A young adult female with benign breast disease says she has increased breast pain and tenderness with menses. In response to this client's concerns, the nurse should: a. discuss the relationship of benign breast disease to breast cancer recommend an over-the-counter analgesic and reducing salt intake Decreasing salt intake and taking a mild analgesic may help with the breast pain. There is no direct link between benign breast disease and the incidence of cancer. The discomfort associated with this disease is cyclical, occurring in the days prior to menstruation, and does not indicate that a biopsy is needed. The condition occurs during the woman's reproductive years, typically during the 20s. Telling the woman that the condition will soon go away is not correct. 12. The nurse is palpating the breasts of an adult female. Normal findings include: a. smooth, elastic breast tissue smooth, elastic breast tissue The breasts should feel smooth, elastic, and symmetrical. The skin of the areola is darker and wrinkled. Unilateral nipple discharge is not a normal finding, and the nurse should refer the client to her healthcare provider for further evaluation. Peau d'orange, orange peel skin, occurs in advanced stages of cancer from blocked lymphatic drainage. Thickening of the skin is abnormal and suggests underlying carcinoma. 13. The nurse notes the presence of gynecomastia in a teenage boy. The nurse understands: a. This condition is abnormal if it is of recent onset. This is a temporary condition in puberty. Gynecomastia (breast enlargement in males) is a normal, temporary condition seen in up to 30% of males at puberty. Gynecomastia is also seen after birth due to circulating maternal hormones and in elderly males. The presence of gynecomastia is considered normal in adolescent males. Men are not at increased risk of developing breast cancer if they have had gynecomastia. This is a normal finding for a male of this age. 14. A young adult female client asks what she can do to reduce her risk for breast cancer. Which statements should the nurse
include in responding to this client's question and concern? a. "Regular exercise can help to decrease your risk for breast cancer." "Regular exercise can
help to decrease your risk for breast cancer." Physical activity in the form of exercise has been found to decrease a woman's risk for breast cancer. Obesity has been linked with breast cancer; thus, maintaining a healthy weight can reduce a woman's risk for breast cancer. Mammography is used for early detection of breast cancer, not prevention. Breastfeeding (especially 1½-2 years) has been shown to decrease a woman's risk for breast cancer; therefore, a woman should be encouraged and supported, not limited. Breast enhancement surgery does not increase a woman's risk for breast cancer; however, implants can make reading mammograms more difficult to interpret. Sets with similar termsHealth Assessment Ch 17 Vocab46 terms Captain__Awesome NSG211 Exam 2 - ch 17 breasts and lympha…47 terms nissy951 Med Surg Ch. 58 Breast Disorders41 terms lliddell95 Health Assessment- Prep-U Ch 20 mastery level 3-642 terms laylahb Sets found in the same folderHealth Assessment Chapter 1716 terms Stephanie_Cavalier Health Assessment Chapter 214 terms Stephanie_Cavalier Health Assessment Chapter 1917 terms Stephanie_Cavalier Exam 2- HA172 terms abbyblair16 Other sets by this creatorEndocrine CH 49 Patho40 terms Stephanie_Cavalier Chapter 11 Disorders of Immune9 terms Stephanie_Cavalier Red Blood Cells Patho20 terms Stephanie_Cavalier White Blood Cells Patho21 terms Stephanie_Cavalier Other Quizlet setsChapter 17 estestbank questions NUR 31945 terms gbomb20 Chapter 18 #FINAL38 terms tayla_abbington2 Health Exam 429 terms sarah_paul37 Related questionsQUESTION What are the 4 factors that determine your BAC 15 answers QUESTION what are the two main neck muscles 14 answers QUESTION True or False: The US government spends relatively little on health care delivery in the US 15 answers QUESTION What is the normal weight of a baby? 15 answers What is the nurse assessing when performing a breast assessment on a client and palpating along the inner aspect of the humerus?What is the nurse assessing when performing a breast assessment on a client and palpating along the inner aspect of the humerus? Lymph nodes drain lymph from the breast and axillae and return it to the bloodstream.
What is the nurse assessing when performing a breast assessment?This allows the examiner to assess the breasts in many positions and observe overall size, shape, symmetry, nipple size, shape, texture, and color.
What is the reason for palpating axillary lymph nodes during a clinical breast examination?Following direct palpation of the breast, the axillary region should be palpated. This is because the axillary lymph nodes are usually the first site of spread in the setting of breast cancer.
When palpating a client's breast The nurse should use?palpate breasts with both the flat of your hand and fingers. follow systematically, in a circular pattern around the nipple or along the radial lines (simulate a clock) or vertical segments and feel the entire breast, including the tail near the axilla.
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What is the nurse assessing when performing a breast assessment on a client and palpating along the inner aspect of the humerus *?
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