physical asssesment breast and lymphatics ATI

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple?

A client reports recent serosanguinous nipple discharge

• A client reports that one nipple has begun to point in a different direction

A client's nipple has remained inverted since childhood

( A client's nipple has a small crust present on the tic

A client reports recent serosanguinous nipple discharge

INCORRECT

The presence of nipple discharge is an unexpected finding that should be reported to the provider. Therefore, the nurse should not include this as an example of an expected variation of the nipple.

A client reports that one nipple has begun to point in a different direction

INCORRECT

My Answer

A change in the direction of a nipple could be an indication of cancer. Therefore, the nurse should not include this as an example of an expected variation of the nipple.

A client's nipple has remained inverted since childhood

CORRECT

The nurse should include nipple inversion since puberty as an example of an expected variation in breast appearance. Nipples are inverted at birth and usually begin to protrude during puberty.

A client's nipple has a small crust present on the tip

INCORRECT

The presence of a crust on the nipple is an unexpected finding that should be reported to the provider. This could be an indication of a medical condition, such as Paget's disease. Therefore, the nurse should not include this as an example of an expected variation of the nipple.

A nurse is teaching a group of newly licensed nurses about routine mammography screenings. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"A 55-year-old client should receive mammography screenings at least every 2 years."

• "Clients can discontinue routine mammography screenines when they are 65 vears old ""

"Clients should begin routine mammography screenings when they are 35 years old."

"A 45-year-old client should receive mammography screenings at least every 5 years."

"A 55-year-old client should receive mammography screenings at least every 2 years."

~ CORRECT

My Answer

Routine mammography screenings are recommended between the ages of 50 and 74 years old and should take place every 2 years. Therefore, this statement indicates an understanding of the teaching.

"Clients can discontinue routine mammography screenings when they are 65 years old."

INCORRECT

Routine mammography screenings are recommended between the ages of 50 and 74 years old and should take place every 2 years.

"Clients should begin routine mammography screenings when they are 35 years old."

INCORRECT

Routine mammography screenings are recommended between the ages of 50 and 74 years old and should take place every 2 years.

"A 45-year-old client should receive mammography screenings at least every 5 years."

INCORRECT

Routine mammography screenings are recommended between the ages of 50 and 74 years old and should take place every 2 years.

A nurse is teaching a group of clients about performing breast self-examinations. Which of the following instructions should the nurse include?

Breasts are the least tender during the first 3 days of the menstrual cycle in clients who are still menstruating.

Breast self-examination can discontinue after menopause.

Breast self-examination should be done about 5 davs after the menstrual cycle begins in clients who are still menstruatine

Benign breast nodules are less prominent during the premenstrual phase in clients who are still menstruating.

Breasts are the least tender during the first 3 days of the menstrual cycle in clients who are still menstruating.

INCORRECT

The nurse should instruct the group that the breasts are often swollen, tender, and more nodular right before and for the first few days of the menstrual cycle. The breasts are smaller and less congested 4 to 7 days after the onset of the menstrual cycle.

Breast self-examination can discontinue after menopause.

INCORRECT

The nurse should instruct the group that the need for breast self-examination is more important after menopause because the risk for breast cancer increases with aging.

Breast self-examination should be done about 5 days after the menstrual cycle begins in clients who are still menstruating.

• CORRECT

My Answer

The nurse should instruct the client to perform breast self-examination 4 to 7 days after the onset of their menstrual cycle. This time is optimal because breasts are at their smallest and least congested. Before onset of menstruation, breasts tend to swell and are more nodular from increasing levels of estrogen.

Benign breast nodules are less prominent during the premenstrual phase in clients who are still menstruating.

INCORRECT

The nurse should instruct the group that breast nodules might be more prominent during the premenstrual phase due to increased estrogen in the body. The client should recheck any nodules noted during the premenstrual phase after menstruation begins.

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse can see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the client's lymph node enlargement?

A supernumerary nipple

Infection

Increased adipose tissue

Psychotropic medication use

A supernumerary nipple

INCORRECT

A supernumerary nipple is an extra nipple that is sometimes found along the embryonic milk lines. This does not cause enlarged lymph nodes.

Infection

~ CORRECT

My Answer

The nurse should recognize that an infection of the hand, breast, or arm can cause lymph nodes in the axillae to enlarge so that they become palpable, and sometimes they can even be visible upon inspection.

Increased adipose tissue

INCORRECT

Increased adipose tissue contributes to the overall size of the breast and surrounding tissue. Loss of breast tissue due to age-related changes can make lumps or nodules more prominent. However, this does not cause enlarged lymph nodes.

Psychotropic medication use

INCORRECT

Psychotropic medications, such as haloperidol spironolactone, can cause benign breast pain, rather than enlargement of axillary lymph nodes.

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the client's past health history? (Select all that apply.)

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•

• • • •

•

"Have you ever had breast disease?"

"Have you experienced breast trauma?"

"Have you had breast surgery?"

"Do you perform breast self-examinations?"

• 'Has anyone in your family had breast cancer?"

"Have you ever had breast disease?" is correct. The nurse should ask whether the client has ever had breast disease, such as fibrocystic changes or cancer, while obtaining the client's past health history.

"Have you experienced breast trauma?" is correct. The nurse should ask whether the client has ever experienced breast trauma while obtaining the client's past health history.

"Have you had breast surgery?" is correct. The nurse should ask the client whether they have had breast surgery while obtaining the client's past health history. Breast surgery can cause atypical hyperplasia of breast tissue, which increases the risk for breast cancer.

"Do you perform breast self-examinations?" is correct. The nurse should ask whether the client performs breast self-examinations while obtaining the client's past health history. It is important for the client to perform breast self-examinations to increase the chance for early detection of a lump.

"Has anyone in your family had breast cancer?" is incorrect. The nurse should ask whether anyone in the client's family has had breast cancer while obtaining a family history on the client, rather than the client's past health history

A nurse is performing a breast inspection during a client's routine physical examination. Which of the following findings should the nurse report to the provider?

'...........,.', • , . , , • . • . .• . • • • • • . . . о . • .. о . .• . о • •. с

Areolas are oval-shaped

Scaley skin at the border of one areola

• Small bumps visible on each areola

Areolas have a darker pigment than the surrounding skin

Areolas are oval-shaped

INCORRECT

The nurse should identify that the areola can be oval-shaped or circular. This finding does not need to be reported to the provider.

Scaley skin at the border of one areola

• CORRECT

My Answer

The nurse should identify that the presence of scaley skin on the breast is an unexpected finding. The nurse should report this finding to the provider for further evaluation.

Small bumps visible on each areola

INCORRECT

The nurse should identify that small bumps visible on the areola are small sebaceous glands known as Montgomery glands. This finding does not need to be reported to the provider.

Areolas have a darker pigment than the surrounding skin

INCORRECT

The nurse should identify that the areolas are expected to have a darker pigment than the surrounding breast skin. This finding does not need to be reported to the provider.

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health? (Select all that apply).

•

•

• 0

Ask the client to describe the process for breast self-examination at the end of the teaching.

Document instructions provided in the client's medical record.

Provide the client with information about the human papilloma virus (HPV) vaccine.

• Review recommendations for mammography based on risk with the client.

_ Begin the teaching by listing national guidelines for breast screening.

•

Ask the client to describe the process for breast self-examination at the end of the teaching is correct. The nurse should ask the client to describe the process for breast self-examination at the end of the teaching to validate their understanding of the information.

Document instructions provided in the client's medical record is correct. The nurse should document any education provided or reinforced with the client in the medical record as part of accurate documentation.

Provide the client with information about the human papilloma virus (HPV) vaccine is incorrect. The nurse should not plan to provide the client with information about the HPV vaccine because this is related to rectal and genitourinary health, rather than breast health.

Review recommendations for mammography based on risk with the client is correct. The nurse should review recommendations for breast screenings, such as mammography, with the client based on their risk factors.

Begin the teaching by listing national guidelines for breast screening is incorrect. The nurse should begin client education by determining the client’s readiness to learn and what information the client knows about breast screening, rather than by listing national guidelines for breast cancer screening.

A nurse is reviewing breast self-examination techniques with a client. Which of the following client statements indicates an understanding of the techniques?

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•

• • • •

• •

"I will use circular motions to feel the texture of my breast tissue."

"I will use the palmar surface of my hands to perform breast palpation."

"I will lie down and put one hand behind my head to examine the breast on the opposite side of my body."

"I will examine my breasts after bathing and drying thoroughly."

"I will use circular motions to feel the texture of my breast tissue."

CORRECT

The client should use small, circular motions to palpate the breast and underlying tissue. Therefore, the nurse should identify this statement as an indication that the client understands breast self-examination techniques.

"I will use the palmar surface of my hands to perform breast palpation."

INCORRECT

The nurse should instruct the client to use the pads of their fingers, rather than the palmar surface of their hands, to detect nodules or lumps when palpating the breast.

"I will lie down and put one hand behind my head to examine the breast on the opposite side of my body."

INCORRECT

My Answer

The nurse should instruct the client to place their hand behind their head from the same side of the body as the breast they are examining. This spreads out the breast tissue and provides access to the axilla, which allows for more effective examination.

"I will examine my breasts after bathing and drying thoroughly."

INCORRECT

The nurse should instruct the client to examine their breasts while showering or bathing because soap and water allow the client to palpate their breasts using smoother movements.

A nurse is discussing breast cancer with a group of clients. The nurse should include that which of the following findings is a potential indication of breast cancer? (Select all that apply.)

Dilation of the hair follicles

Bilateral tissue enlargement

Nipple retraction

A dry, scaling rash on the nipple

• Palpable Montgomery glands

Dilation of the hair follicles is correct. The nurse should include that dilation of the hair follicles of the breast, also known as peau d’orange, is a potential indication of possible breast cancer that should be reported to the provider.

Bilateral tissue enlargement is incorrect. The nurse should identify that bilateral tissue enlargement is not an indication of breast cancer.

Nipple retraction is correct. The nurse should include that nipple retraction is a potential indication of breast cancer that should be reported to the provider. The client should also report the presence of nipple discharge.

A dry, scaling rash on the nipple is correct. The nurse should include that a dry, scaling rash on the nipple is a potential indication of breast cancer that should be reported to the provider.

Palpable Montgomery glands is incorrect. The nurse should identify that palpable Montgomery glands is an expected finding of the breasts that is not an indication of breast cancer. Montgomery glands are elevated sebaceous glands within the areola, which are palpable as small bumps.

A nurse is performing a breast examination on a client and notices that the client's right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition?

• 0

) Adverse effect of beta-blocker medication

Recent onset of menopause

Arterial occlusion on the right side

Recent surgery on the right side

Adverse effect of beta-blocker medication

INCORRECT

The nurse should identify that beta-blocker medications can cause clear nipple discharge. However, beta-blocker medication is not a potential cause for the client's condition.

Recent onset of menopause

INCORRECT

The onset of menopause causes decreased estrogen levels, which causes the breasts to become smaller and less firm. However, the onset of menopause is not a potential cause for the client's condition.

Arterial occlusion on the right side

INCORRECT

The nurse should recognize that arterial occlusion would cause pain distal to the blockage. Deep vein thrombosis might cause edema, but usually occurs in the lower extremities.

Recent surgery on the right side

• CORRECT

My Answer

Surgery on the client's right side, such as a mastectomy, can disrupt the flow of lymphatic drainage, which can cause edema. Therefore, the nurse should identify that recent surgery might be the cause of the client's condition.

A nurse is caring for a client who was recently diagnosed with gynecomastia. Which of the following should the nurse identify as a potential cause of this condition?

•

•

Presence of the BRCA1 gene

Medication adverse effects

Decreased estrogen levels

Decreased thyroid hormone levels

Presence of the BRCA1 gene

INCORRECT

My Answer

The BRCA1 gene is a risk factor for breast cancer rather than gynecomastia. Gynecomastia is a benign condition.

Medication adverse effects

CORRECT

The nurse should identify that gynecomastia, or a swelling of the breast tissue in males, can be caused by medication adverse effects. This condition can also be caused by hormonal changes or weight gain.

Decreased estrogen levels

INCORRECT

Gynecomastia can be caused by increased, rather than decreased, estrogen levels.

Decreased thyroid hormone levels

INCORRECT

The nurse should identify that hyperthyroidism, rather than decreased thyroid hormone levels, can cause gynecomastia.

A nurse is inspecting a client's axillae. Which of the following should the nurse identify as an expected finding?

Skin is deeply pigmented

Presence of plaques

Fixation of tissue during arm movement

Skin has a uniform consistency

Skin is deeply pigmented

INCORRECT

My Answer

The nurse should identify deep pigmentation of the axillae as an unexpected finding that requires further evaluation. Discoloration can be a manifestation of a condition such as diabetes mellitus or polycystic ovary disease.

Presence of plaques

INCORRECT

The nurse should identify plaques as an unexpected finding when inspecting the skin. Plaques are flat, raised portions of skin that can be an indication of a skin condition, such as psoriasis.

Fixation of tissue during arm movement

INCORRECT

The nurse should identify a fixation, or a segment of tissue that does not move as it should during arm movement, as an unexpected finding.

Fixation of tissue can be an indication of cancer.

Skin has a uniform consistency

CORRECT

The nurse should identify that the client's axillae should be smooth and intact.

A nurse is performing a breast inspection on a client. Which of the following findings should the nurse report to the provider?

Striae

Flat, brown nevi

Visible capillaries beneath the skin surface bilaterally

Dimpling

Striae

INCORRECT

The nurse should identify that striae, also known as "stretch marks," are linear marks on the skin that appear lighter or darker than the surrounding skin tone which indicates prolonged stretching. This finding does not need to be reported to the provider.

Flat, brown nevi

INCORRECT

The nurse should identify flat, brown nevi, or moles, as an expected variation that does not need to be reported to the provider.

Visible capillaries beneath the skin surface bilaterally

INCORRECT

The nurse should identify that visible capillaries beneath the skin surface bilaterally are expected variations that do not need to be reported to the provider. However, the nurse should report the presence of dilated veins beneath the skin occurring only on one breast.

Dimpling

• CORRECT

My Answer

The nurse should identify that dimpling, warmth, or a rash on the client's breast are unexpected findings that should be reported to the provider for further evaluation.

A nurse is teaching a client about performing a breast self-examination at home. In which order should the nurse instruct the client to perform the steps of breast self-examination? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

• •

Inspect the breasts for changes in shape, color, or contour.

Lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers.

Look at the breasts in front of a mirror with hands placed on hips.

Inspect the nipples for a rash or drainage.

Palpate each breast from the outer edge, moving from top to bottom across the breast.

Look at the breasts in front of a mirror with hands placed on hips.

Inspect the breasts for changes in shape, color, or contour.

Inspect the nipples for a rash or drainage.

Lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers.

Palpate each breast from the outer edge, moving from top to bottom across the breast.

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the client's breasts?

•

•

Standing upright with their arms held straight out to their sides

) Bending over at the waist with hands reaching toward the toes

Sitting straight up with arms relaxed and close to the body

( Lving supine with hands clasped together at the umbilicus

Standing upright with their arms held straight out to their sides

INCORRECT

The nurse should not have the client stand upright with their arms held out to their sides for a breast inspection.

Bending over at the waist with hands reaching toward the toes

INCORRECT

Although the nurse could have the client bend forward as part of a breast inspection, the nurse should not have the client reach towards their toes because this would cover the breast area and prevent observation.

Sitting straight up with arms relaxed and close to the body

~ CORRECT

My Answer

Prior to inspecting the client's breasts, the nurse should place the client in a seated or standing position with their arms relaxed at their sides. The nurse should also drape the client's gown at waist-level to allow for visualization of the anterior chest.

Lying supine with hands clasped together at the umbilicus

INCORRECT

The nurse should not have the client lie in the supine position with their hands clasped at the umbilicus for a breast inspection. However, the nurse should instruct the client to lie down in preparation for breast palpation by the provider.