chapter 20 301 – Flashcards

The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse to assess? A) Upper inner quadrant B) Lower inner quadrant C) Upper outer quadrant D) Lower outer quadrant

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: a. The largest quadrant of the breast. b. The location of most breast tumors. c. Where most of the suspensory ligaments attach. d. More prone to injury and calcifications than other locations in the breast.

The nurse has asked a female client if she has noticed any lumps or swelling in her breasts. After the client responds "yes," which question should the nurse ask next? A) "Have any of the other women in your family had this happen?" B) "Has there been any corresponding change in your breast size?" C) "Does the lump change over the course of your menstrual cycle?" D) "What do you think is causing this change?"

When taking a health history for a female client, which factor should the nurse identify as placing the client at increased risk for breast cancer? A) The client smokes six to eight cigarettes per day B) The client had her first child at age 38 C) The client breast-fed her child for a full year D) The client has a low body mass index

Which of the following factors should a nurse include when discussing risk factors about breast cancer for a group of women? A) Early menarche B) One or more pregnancies before age 20 C) Consumption of a high-protein diet D) Early menopause

While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse should suspect which of the following? A) Pregnancy B) Fibrocystic changes C) Malignancy D) A low platelet count

A 42-year-old female client says she does not perform breast self-examination because she believes that mammograms are more thorough. Which response by the nurse would be most appropriate? A) "You should do the exam. It's the best way to detect breast cancer early." B) "Be sure to have your breasts checked by a doctor and have a mammogram every year." C) "Mammograms don't always detect the lumps that you might feel." D) "Once you hit age 50, you really won't have a choice about doing them."

An 18-year-old woman complains because one breast is larger than the other. What additional interview data would suggest a need for referral? A) The client states that she is sexually active. B) The client states that she does not perform breast self-examination. C) The client states that her problem affects her body image. D) The client states that this represents a sudden change in her breast size.

The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. Which of the following would the nurse expect to find? A) Orange-peel skin B) Nipple retraction C) Dark pink areola D) Red and scaling on the areola

A woman reports a sudden onset of spontaneous nipple discharge. Which of the following would be the nurse's most appropriate action? A) Refer the client for cytologic study of the discharge. B) Observe the breast for eversion of the nipples. C) Reassure the woman that this is a result of hormonal fluctuations. D) Collect a sample for culture and sensitivity testing.

The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which position would be most appropriate? A) Standing B) Supine C) Semi-Fowlers D) Sitting

A client has large, pendulous breasts. Which of the following would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling? A) Have the client stand and lean forward B) Have the client lie on her side C) Have the client sit and then lean forward D) Have the client lie flat on her back

The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment? A) Use the flat pads of three fingers. B) Use the fingertips of both hands. C) Gently pinch the skin between two fingers. D) Use the palm of one hand.

A woman appears restless and is wringing her hands prior to having a clinical breast examination performed. Which statement by the nurse would be most appropriate? A) "I know you are worried, but your risk for cancer is low." B) "You need to pay attention to these instructions so we can finish as quickly as possible." C) "You seem to be anxious. Can you tell me what you are thinking?" D) "You appear restless but I can assure you that your doctor is very good."

A nurse has completed the assessment of a client's breasts. The nurse should suspect that the client has fibroadenomas based on which findings? A) Lobular, ovoid, or round lesions B) Irregular, firm cysts C) Round, defined mobile cysts D) Nondefined, mobile cysts

After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate their breasts using which pattern? A) A circular pattern B) A clockwise pattern C) A random pattern D) An up-and-down pattern

When palpating a female client's axillae, which of the following actions is most appropriate? A) Have the client hold the arm of the side being examined slightly away from the body. B) Tell the client to raise her arm on the side being examined up over her head. C) Hold the client's elbow of the side being examined with one hand. D) Have the client lean forward from the waist with arms outstretched.

When palpating a female client's axillae, which finding would the nurse document as normal? A) Node size is 1.2 cm. B) Nodes are fixed. C) Nodes are hard. D) Nodes are discrete.

A nurse is teaching an older adult client about breast self-examination. The nurse includes teaching on expected changes in the client's breasts due to aging. Which of the following would the nurse include? A) Increase in glandular tissue B) Increase in fatty tissue C) Larger nipple area D) Less "granular" in texture

A group of students is preparing for a quiz on breast assessment and the assessment findings that are associated with breast cancer. The students demonstrate understanding of the material when they identify which of the following? Select all that apply. A) Irregular, firm lumps B) Elastic, tender, mobile lumps C) Dimpling and nipple retraction D) Orange peel-like appearance E) Redness and warmth with smooth texture F) Breast fullness and pain

The nurse is beginning the inspection of a young adult client's breasts. The client states, "My left breast has always been a bit bigger than the right." How should the nurse best respond to the client's statement? A) "Many women have this, and it's rarely a sign of a health problem." B) "That's very normal, and it usually resolves over time as you get older." C) "If you lose some weight, the size disparity will likely decrease." D) "I'll make sure to refer to the doctor to get this assessed further."

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 nurse's best response? Tell the mother that: a. Breast development is usually fairly symmetric and that the daughter should be examined right away. b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls. c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal. d. It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue.

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? a. Black b. White c. Asian d. American Indian

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? a. 37 year old who is slightly overweight b. 42 year old who has had ovarian cancer c. 45 year old who has never been pregnant d. 65 year old whose mother had breast cancer

The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? a. "BSE is more important than ever for you because you have never had any children." b. "BSE is so important because one out of nine women will develop breast cancer in her lifetime." c. "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." d. "BSE will save your life because you are likely to find a cancerous lump between mammograms."

The nurse has completed the assessment of a client's breast and lymphatic system. The nurse has ended the assessment by offering to teach the client how to perform breast self-examination (BSE). The client states, "That's alright. I already know how to do that." What should the nurse do next? A) Encourage the client to perform BSE as often as possible. B) Ask the client to demonstrate BSE. C) Encourage the client to promote BSE to her peers. D) Reiterate the correct technique for BSE.

If a patient reports a recent breast infection, then the nurse should expect to find ________ node enlargement. a. Nonspecific b. Ipsilateral axillary c. Contralateral axillary d. Inguinal and cervical

In which of the following male clients would gynecomastia be considered to be an expected assessment finding? A) A 14-year-old boy who began puberty last year B) An older adult who takes antihypertensive medications C) A 59-year-old man who has been exposed to heavy metals in the workplace D) A male client who has been diagnosed with breast cancer

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Ignore it. Benign breast enlargement in men is not unusual. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

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. a. Malnutrition b. Hyperthyroidism c. Type 2 diabetes mellitus d. Liver disease e. History of alcohol abuse

The nurse has palpated a lump in a female patient's 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? a. Shape of the lump b. Consistency of the lump c. Size of the lump d. Whether the lump is solitary or multiple