Ch 20 Breasts and Lymphatic System

22. A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following? A) "How would you describe your pain? Is it sharp? Is it an ache?" B) "Has the pain changed over time?" C) "Would you describe the pain as being constant or as intermittent?" D) "Is there anything that makes the pain worse or better?"

A) "How would you describe your pain? Is it sharp? Is it an ache?"

25. 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) "Many women have this, and it's rarely a sign of a health problem."

29. 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

A) A 14-year-old boy who began puberty last year

2. During a prenatal class, a participant says that she was told that her breasts are not large enough to breastfeed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which of the following variables? A) Amount of glandular tissue B) Breast size and weight C) Amount of fatty tissue D) Depth of the subcutaneous fat layer

A) Amount of glandular tissue

5. 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

A) Early menarche

20. 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

A) Irregular, firm lumps C) Dimpling and nipple retraction D) Orange peel-like appearance

15. 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

A) Lobular, ovoid, or round lesions

10. 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.

A) Refer the client for cytologic study of the discharge.

13. 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) Use the flat pads of three fingers.

7. 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."

B) "Be sure to have your breasts checked by a doctor and have a mammogram every year."

28. The nurse is palpating the axillary lymph nodes of a client who has been experiencing recent malaise. The nurse should consider a lymph node to be enlarged if its diameter exceeds what size? A) 0.5 cm B) 1 cm C) 2 cm D) 2.5 cm

B) 1 cm

24. 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.

B) Ask the client to demonstrate BSE.

23. During the health interview, the nurse asks a middle-aged client at what age she began menstruating. This question addresses a risk factor for what health problem? A) Mastitis B) Breast cancer C) Benign breast disease D) Paget's disease

B) Breast cancer

19. 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

B) Increase in fatty tissue

4. 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

B) The client had her first child at age 38

21. A client has presented for care to the clinic, stating, "I'm pretty sure that I feel a new lump in my breast." After confirming the presence of a lump, what action should the nurse take? A) Arrange for the client to be brought to the hospital emergency department immediately. B) Tell the client to monitor the lump for the next three weeks and seek care if it increases in size. C) Arrange for a prompt referral to her primary care provider. D) Facilitate a referral to an oncologist if more lumps emerge in the coming weeks.

C) Arrange for a prompt referral to her primary care provider.

17. 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.

C) Hold the client's elbow of the side being examined with one hand.

6. 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

C) Malignancy

27. The nurse is assessing an adult client's areolas and nipples. What assessment finding would most clearly warrant referral? A) Small Montgomery tubercles are present on the areolas. B) Supernumerary nipples are present. C) The patient's nipple has recently become inverted. D) The patient's areola puckers upon palpation.

C) The patient's nipple has recently become inverted.

1. 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

C) Upper outer quadrant

16. 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

D) An up-and-down pattern

18. 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.

D) Nodes are discrete.

3. 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?"

C) "Does the lump change over the course of your menstrual cycle?"

14. 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."

C) "You seem to be anxious. Can you tell me what you are thinking?"

12. 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

C) Have the client sit and then lean forward

26. The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding? A) Confirm whether the client has breast implants in place. B) Ask the client about any history of mastitis (breast infection). C) Explain to the client that this is a normal, age-related change. D) Promptly refer the client for further medical assessment.

D) Promptly refer the client for further medical assessment.

30. Assessment of a client's breasts reveals tenderness on palpation and diffuse redness. What collaborative problem is most clearly suggested by these data? A) RC: Breast cancer B) RC: Benign breast disease C) RC: Hematoma D) RC: Infection

D) RC: Infection

9. 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

D) Red and scaling on the areola

11. 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

D) Sitting

8. 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.

D) The client states that this represents a sudden change in her breast size.