Breast, Axillae, and Regional Lymphatics

Chapter 18

Which of the following statements is *true* regarding the internal structures of the breast? The breast is made up of:

Fibrous, glandular, and adipose tissues. \n

* The breast is made up of glandular, fibrous (including the suspensory ligaments), and adipose tissues.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:

The location of most breast tumors.



*

The upper outer quadrant is the site of most breast tumors. In the upper outer quadrant, the nurse should notice the axillary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.

In performing an assessment of a womans axillary lymph system, the nurse should assess which of these nodes?

Central, lateral, pectoral, and subscapular \n

* The breast has extensive lymphatic drainage. Four groups of axillary nodes are present: (1) central, (2) pectoral

(anterior), (3) subscapular (posterior), and (4) lateral.

If a patient reports a recent breast infection, then the nurse should expect to find ________ node enlargement.

Ipsilateral axillary



* The breast has extensive lymphatic drainage. Most of the lymph, more than 75%, drains into the ipsilateral, or

same side, axillary nodes.

A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, Am I normal? I dont seem to need a bra yet, but I have some friends who do. What if I never get breasts? The nurses best response would be:

I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.



* Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the

girls feelings by using statements like dont worry or by sharing personal experiences. The beginning of breast

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurses best response? Tell the mother that:

Although an examination of her daughter would rule out a problem, her breast development is most likely normal.



*

Occasionally, one breast may grow faster than the other, producing a temporary asymmetry, which may cause some distress; reassurance is necessary. Tenderness is also common.

A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that:

The girl began to develop breasts.



*

Full development from stage 2 to stage 5 takes an average of 3 years, although the range is 1 to 6 years. Pubic hair develops during this time, and axillary hair appears 2 years after the onset of pubic hair. The beginning of breast development precedes menarche by approximately 2 years. Menarche occurs in breast development stage 3 or 4, usually just after the peak of the adolescent growth spurt, which occurs around age 12 years.

A woman is in the family planning clinic seeking birth control information. She states that her breasts change all month long and that she is worried that this is unusual. What is the nurses best response? The nurse should tell her that:

Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.



*

Breasts of the nonpregnant woman change with the ebb and flow of hormones during the monthly menstrual cycle. During the 3 to 4 days before menstruation, the breasts feel full, tight, heavy, and occasionally sore. The breast volume is smallest on days 4 to 7 of the menstrual cycle.

A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts?

She can expect her areolae to become larger and darker in color



*

The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. (The brown color fades after lactation, but the areolae never return to their original color). A venous pattern is an expected finding and prominent over the skin surface and does not need to be reported. After the fourth month of pregnancy, colostrum, a thick, yellow fluid (precursor to milk), may be expressed from the breasts.

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is *correct*?

You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy.



*

After the fourth month, colostrum may be expressed. This thick yellow fluid is the precursor of milk, and it contains the same amount of protein and lactose but practically no fat. The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection; therefore, breastfeeding is important.

A 65-year-old patient remarks that she just cannot believe that her breasts sag so much. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:

The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.



* After menopause, the glandular tissue atrophies and is replaced with connective tissue. The fat envelope also atrophies, beginning in the middle years and becoming significant in the eighth and ninth decades of life. These changes decrease breast size and elasticity; consequently, the breasts droop and sag, looking flattened and

flabby.

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurses best course of action?

Explain that this condition may be the result of hormonal changes, and recommend that he see his physician.



* Gynecomastia may reappear in the aging man and may be attributable to a testosterone deficiency.

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next?

Assess the girls weight and body mass index (BMI).



*

Research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before age 8 years for black girls and age 10 years for white girls) and early menarche.

The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for developing breast cancer?

Black



* The incidence of breast cancer varies within different cultural groups. White women have a higher incidence of breast cancer than black women starting at age 45 years; but black women have a higher incidence before age

45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer

The nurse is preparing for a class in early detection of breast cancer. Which statement is *true* with regard to breast cancer in black women in the United States?

Black women are more likely to die of breast cancer at any age.



*

Black women have a higher incidence of breast cancer before age 45 years than white women and are more likely to die of their disease. In addition, black women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. These racial differences in mortality rates may be related to an insufficient use of screening measures and a lack of access to health care.

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurses most appropriate response to this would be:

I would like some more information about the pain in your left breast.



*

Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the patients pain rather than make statements that ignore the patients concerns.

During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next?

Ask the patient some additional questions about the medications she is taking.



*

The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be normally expressed after the fourth month of pregnancy.

During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask?

Where did the rash first appear on the nipple, the areola, or the surrounding skin?

\
* The location where the rash first appeared is important for the nurse to determine. Paget disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at the nipple unless it is a result of breastfeeding. It usually starts on the areola or surrounding skin and then spreads

to the nipple.

A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be *true*? The presence of benign breast disease:

Makes it hard to examine the breasts.



*

The presence of benign breast disease (formerly fibrocystic breast disease) makes it hard to examine the breasts; the general lumpiness of the breast conceals a new lump. The other statements are not true.

During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms do a much better job than I ever could to find a lump. The nurse should explain to her that:

BSEs may detect lumps that appear between mammograms.



*

The monthly practice of BSE, along with clinical breast examination and mammograms, are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms.

During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is *accurate*?

Breastfeeding provides the perfect food and antibodies for your baby.



*

Exclusively breastfeeding for 6 months provides the perfect food and antibodies for the baby, decreases the risk of ear infections, promotes bonding, and provides relaxation.

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer?

65 year old whose mother had breast cancer

\
* Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or

daughter) and being older than 50 years of age.

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is *true* about this finding?

Asymmetry is not unusual, but the nurse should verify that this change is not new.



*

The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.

The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?

Woman whose nipples are in different planes (deviated).



*

The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer may cause fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings.

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is *most* accurate?

Whether the inversion is a recent change should be determined.



*

The nurse should distinguish between a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired disease.

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:

Slowly lift her arms above her head, and note any retraction or lag in movement.



*

The woman should be directed to change position while checking the breasts for signs of skin retraction. Initially, she should be asked to lift her arms slowly over her head. Both breasts should move up symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms.

The nurse should notice whether movement of one breast is lagging.

The nurse is palpating a female patients breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?

Supine with the arms raised over her head



*

The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and medially displace it. Any significant lumps will then feel more distinct.

Which of these clinical situations would the nurse consider to be outside normal limits?

A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.



*

If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breasts.

A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to:

Palpate the unaffected breast first.



*

If the woman mentions a breast lump she has discovered herself, then the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual.

The nurse has palpated a lump in a female patients right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o’clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation?

Size of the lump



*

If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location, (2) sizejudge in centimeters in three dimensions: width length thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.

The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?

The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.



*

The nurse should help each woman establish a regular schedule of self-care. The best time to conduct a BSE is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. The pregnant or menopausal woman who is not having menstrual periods should be advised to select a familiar date to examine her breasts each month for example, her birth date or the day the rent is due.

The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?

BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations.



* The nurse should stress that a regular monthly BSE will familiarize the woman with her own breasts and their normal variations. BSE is a positive step that will reassure her of her healthy state. While teaching, the nurse should focus on the positive aspects of BSE and avoid citing frightening mortality statistics about breast

cancer, which may generate excessive fear and denial that can obstruct a womans self-care actions.

A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem flat and flabby. The nurses best reply would be:

Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging.



* The hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more

pendulous, flattened, and sagging.

A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was nothing to worry about. The examination validates the presence of a mass in the right upper outer quadrant at 1 oclock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. The nurse replies:

Because of the change in consistency of the lump, it should be further evaluated by a physician.



*

A lump that has been present for years and is not exhibiting changes may not be serious but should still be explored. Any recent change or a new lump should be evaluated. The other responses are not correct.

During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate?

Examine your breasts shortly after your menstrual period each month.



*

The best time to conduct a BSE is shortly after the menstrual period when the breasts are the smallest and least congested.

The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is:

On the same day every month.

* \

Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform BSEs on a monthly basis. Choosing the same day of the month is a helpful reminder to perform the examination

While inspecting a patients breasts, the nurse finds that the left breast is slightly larger than the right with the bilateral presence of Montgomery glands. The nurse should:

Consider these findings as normal, and proceed with the examination.



*

Normal findings of the breast include one breast (most often the left) slightly larger than the other and the presence of Montgomery glands across the areola.

During an examination, the nurse notes a supernumerary nipple just under the patients left breast. The

patient tells the nurse that she always thought it was a mole. Which statement about this finding is *correct*?

This variation is normal and not a significant finding.



*

A supernumerary nipple looks like a mole, but close examination reveals a tiny nipple and areola; it is not a significant finding.

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as:

Peau dorange.



*

This condition is known as *peau dorange*. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel appearance, and this condition suggests cancer.

When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is *correct*? The mother needs to:

Temporarily discontinue nursing on the affected breast, and manually express milk and discard it.



* With a breast abscess, the patient must temporarily discontinue nursing on the affected breast, manually

express the milk, and then discard it. Nursing can continue on the unaffected side.

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3 C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect?

Mastitis



*

The symptoms describe mastitis, which stems from an infection or stasis caused by a plugged duct. A plugged duct does not have infection present.

During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it started doing that a few months ago. This finding suggests:

Retracted nipple.



*

The retracted nipple looks flatter and broader, similar to an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts. The nurse should not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixed.

A 54-year-old man comes to the clinic with a horrible problem. He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is *true*?

One percent of all breast cancers occurs in men. \n

* One percent of all breast cancers occurs in men. The early spreading to axillary lymph nodes is attributable to

minimal breast tissue.

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? *Select all that apply*.

Nontender mass

Hard, dense, and immobile

Irregular, poorly delineated border

\
* Cancerous breast masses are solitary, unilateral, and nontender. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They

are often painless, although the person may experience pain. They are most common in the upper outer quadrant. A dull, heavy pain on palpation and a mass with a rubbery texture and a regular border are characteristics of benign breast disease.

\

The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? *Select all that apply*.

Hyperthyroidism

Liver disease

History of alcohol abuse