Chapter 18 Breasts and Axillae

The nurse working in a predominately-Hispanic community outlines a breast health screening. Which should the nurse be aware of in order to provide the most culturally competent care to this population? 1. Breast cancer is the leading cause of cancer death in Hispanic women. 2. This cultural group is strict about performing monthly self-breast exams. 3. Hispanic women have a higher incidence of breast cancer after age 40. 4. Hispanic women have an open attitude about private issues.

Correct Answer: 1 Breast cancer is the leading cause of cancer death in Hispanic women, and it is common for this particular cultural group to believe that looking at or touching themselves is prohibited. Caucasian women have a higher incidence of breast cancer after age 40 than do women in other racial and ethnic groups.

A female client asks the nurse when the best time is to perform self-breast examination (SBE). Which response by the nurse is the most appropriate? 1. "If you are still menstruating the best time is about 5 days after your period begins each month." 2. "If you are postmenopausal the best time is at the beginning of each month." 3. "It doesn't really matter as long as you keep a record of when you perform the exam." 4. "Your primary care provider can tell you when the best time is for you."

Correct Answer: 1 For females who are still menstruating, 5 days after the period begins is the best time to perform SBE on a monthly basis since there is less hormonal influences on the breast tissue at this time, and it provides a consistent timetable for SBE. If the female is postmenopausal there is no benefit to performing SBE at the beginning of each month, as long as she performs SBE at the same time each month. It is not necessary for the primary care provider to set a schedule for the client to perform SBE.

The nurse is assessing a client and confirms the presence of galactorrhea. Which conclusion by the nurse is the most appropriate? 1. It suggests an endocrine disorder. 2. It may indicate a malignancy. 3. It suggests a breast infection. 4. It is usually indicative of lactation.

Correct Answer: 1 Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressants and antihypertensives. Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma, or cancer. Infections of the breast cause enlargement and tenderness of the axillary lymph nodes.

The nurse is using inspection to assess the breasts of a female client. Which finding might the nurse obtain using this assessment technique? 1. Symmetry. 2. Hard nodules. 3. Tenderness. 4. Skin consistency.

Correct Answer: 1 Symmetry is the only finding that the nurse would assess using the technique of inspection when examining the breasts. The remaining findings would all be obtained using the technique of palpation.

The nurse is interviewing a 37-year-old client for breast cancer risks. Which statement by the client indicates an appropriate understanding of the risks associated with breast cancer? 1. "I know my risk for breast cancer increases with age." 2. "A mammogram every three years is my goal." 3. "I will see my healthcare provider every two years for a breast examination." 4. "My family history is negative so I do not need to worry."

Correct Answer: 1 The risk of breast cancer increases with aging, especially after 35-40 years of age. The most current American Cancer Society guidelines for breast cancer screening include: Mammography biennial screening between the ages of 50 and 74 years; beginning biennial mammography before the age of 50 should be an individual decision based on cancer risk, and values regarding benefit and harm associated with mammography; annual breast examination by a healthcare provider every 3 years for women from age 20 to 40 years, and annually thereafter; self-breast examination is an option for women to consider beginning at the age of 20 All clients, regardless of family history, should be aware of screening guidelines.

While the nurse is counseling a client about fibrocystic breast disease, the client asks if having this disorder will lead to cancer. Which response by the nurse is the most appropriate? 1. "There is no direct link between this disease and breast cancer." 2. "You will need to ask the primary healthcare provider that question." 3. "This disease is a form of cancer." 4. "Why are you so worried about this?"

Correct Answer: 1 There is no direct link between fibrocystic disease and the incidence of cancer. The disease is not a form of cancer, and the remaining two choices do not address the client's concerns.

Select all that apply. The nurse is conducting a breast health workshop for a group of women. Which would the nurse include in this workshop when outlining risk factors for breast cancer? 1. Caucasian race. 2. Positive family history. 3. Low socioeconomic status. 4. Hormone replacement therapy. 5. Female age 35 to 40.

Correct Answer: 1, 2, 3, 4 Caucasian females over the age of 40, positive family history, low socioeconomic status, and taking hormone replacement therapy are risk factors for breast cancer. Females from 35 to 40 years of age are not at a high risk for developing breast cancer.

Select all that apply. The nurse is teaching an older adult client about breast self-examination (BSE). Which should the nurse provide during this instruction? 1. Additional lighting. 2. Increased time. 3. Opportunity for questions. 4. Large-print handouts. 5. A quiz at the end of the instruction.

Correct Answer: 1, 2, 3, 4 More time may be required for the focused interview of the older client who may have a more difficult time talking about something as private as the breasts. Limited range of motion and failing eyesight are some of the physical changes that accompany the aging process. Providing additional lighting, moving at a slower pace, and using handouts or pamphlets with large print may be helpful. A quiz would not be indicated as this may cause the client to experience undue stress.

Select all that apply. The nurse is examining a client with a history of benign breast disease. Which findings does the nurse anticipate when assessing this client's breasts? 1. Straw-colored discharge from the nipples. 2. Freely movable masses. 3. Hard, fixed nodules. 4. Thickened breast tissue. 5. Masses with well-defined boundaries.

Correct Answer: 1, 2, 4, 5 Upon palpation of fibrocystic breasts, the masses feel soft, well demarcated and freely movable. Discharge from the nipples may be clear, straw-colored, milky, or green. These symptoms are a result of fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst formation. Hard, fixed nodules are suggestive of cancer of lymphoma.

Select all that apply. The nurse is planning to perform a breast examination of a female client. When preparing the client for the examination, the nurse will inform the client to expect which techniques? 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Client interview.

Correct Answer: 1, 2, 5 Inspection, palpation, and the client interview are necessary for a complete assessment of the breasts. Percussion and auscultation are not assessment techniques used on breast tissue.

Select all that apply. The nurse is compiling statistics for a breast cancer awareness presentation for a group of women. Which facts about breast cancer are appropriate for the nurse to include in the presentation? 1. Breast cancer is one of the most common cancers in females. 2. Rates are on the decline. 3. Associated mortality has declined. 4. Diagnostics have improved. 5. 25% of females in Western countries are genetically predisposed.

Correct Answer: 1, 3, 4 All of the statements are true with the exception of breast cancer rates, which are actually on the increase, not the decline; and 10% of females in Western countries, rather than 25%, are genetically predisposed to breast cancer.

During a focused assessment, the female client reports breast tenderness, swelling, and lymph node enlargement around the time of her period. Which response by the nurse is the most appropriate? 1. "This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly." 2. "Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider." 3. "As long as you have not detected any lumps you have nothing to worry about." 4. "Do you have a history of fibrocystic breast disease? These symptoms are usually seen with this disease."

Correct Answer: 2 "Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider" is the best response since these are typical symptoms associated with the fluctuation of hormone levels during menses, but should still be reported. Nodularity is a benign condition, but the client does not mention any nodules being present. Stating "As long as you have not detected any lumps you have nothing to worry about," may lead the client to feel that complaints are not justified unless lumps are present. Fibrocystic breast disease is seen with fluctuation of hormone levels with menses but typically has several other symptoms in addition to breast pain, including bilateral masses upon palpation that feel soft, well demarcated, and freely movable, and clear, straw colored, milky, or green discharge from the nipples.

The nurse is asking a client questions regarding lifestyle patterns. Which statement by the client would alert the nurse to possible risk for breast cancer? 1. "I work in a chemical factory." 2. "I drink two glasses of wine each night." 3. "I have smoked two packs of cigarettes daily for four years." 4. "I occasionally have unprotected sexual contact with unknown partners."

Correct Answer: 2 Research indicates that a high-fat diet may increase a woman's risk of developing breast cancer as well as alcohol intake in excess of nine drinks per week. Exposure to chemicals and cigarette smoke would place the client at risk for developing lung-related cancers or disease, and unprotected sexual contact increases risk for STDs, HIV, as well as cervical cancer.

The nurse is teaching a group of high school males about self-breast examination. Which comment by a participant in the teaching session indicates appropriate understanding? 1. "I need to be concerned only if I have pain in my chest." 2. "I know that I need to do monthly self-breast exams." 3. "I'll be able to know about problems if I see changes in my chest." 4. "Breast cancer is not something I have to worry about."

Correct Answer: 2 Teaching the male client to do monthly breast self-examinations is as important as it is for the female client. Breast cancer in the male is usually identified as a hard nodule fixed to the nipple and underlying tissue and is best detected by palpation. Normally, the male breast feels like a thin disc of tissue under a flat nipple and areola. Pain may or may not be present. Since the most common area for nodules to occur in the male breast is near the nipple, other signs like dimpling, asymmetry, peau d'orange, and areolar color changes may not be as noticeable.

The nurse is conducting a focused interview for an adult female client who is experiencing breast discomfort. The client states that the discomfort has increased over the last 6 months. Upon assessment, the nurse notes that the client has round, mobile masses with smooth borders in all quadrants bilaterally. The client's last mammogram was conducted 6 months ago and the findings support the current assessment findings. Based on this data, which statement by the nurse is the most appropriate? 1. "You will need to have a biopsy as your symptoms indicate cancer." 2. "You will need to wear a bra that offers you more support." 3. "You will need to increase your salt intake." 4. "You should not worry about these findings."

Correct Answer: 2 The client's symptoms are indicative of fibrocystic breast disease. Wearing a supportive bra decreases the discomfort associated with this disease process. A biopsy would not be warranted until another mammogram is performed if the healthcare provider suspects carcinoma. A decrease in salt intake is recommended, not an increase. Telling the client not to worry is dismissive and not appropriate.

A female client is hospitalized with injury and tissue destruction of the left pectoralis major and serratus anterior muscles due to a motor vehicle accident. The nurse would include which information during the discharge teaching? 1. Prosthetic devices. 2. Support bras. 3. Plastic surgery. 4. Physical therapy.

Correct Answer: 2 The overall contour of the breasts is determined by the suspensory ligaments, which provide support, and the major muscles of support are the pectoralis major and serratus anterior muscles. The major function of the muscles of the chest wall is to support breast and lymphatic tissue. Undergarments, which provide needed support after discharge, are an important part of the client's recovery—for emotional as well as physical health. Although prostheses, plastic surgery, and physical therapy may all be part of the comprehensive care plan, supporting the breast and lymph tissue until such time as muscle strength is restored or reconstructed would be an important nursing intervention.

Select all that apply. The nurse is preparing an educational session regarding the causes for male gynecomastia. Which items will the nurse include in the session? 1. Breast cancer. 2. Infants following birth. 3. The onset of puberty. 4. Hormone therapy. 5. Breast infection.

Correct Answer: 2, 3, 4 Gynecomastia is a temporary condition of breast enlargement in males. It is most commonly seen in infants, at puberty, and in older males. In older males it may accompany hormonal treatment for prostate cancer. Cancer of the breast in males typically manifests as a hard nodule fixed to the nipple and underlying tissue, and nipple discharge may be present. Gynecomastia is not associated with infection of the breast.

Select all that apply. During a health assessment, a male client voices concern that he is at risk for breast cancer. The nurse is aware that further evaluation of the client's history should focus on predisposing factors that increase the chance for breast cancer in males. The interview should include questions related to which factors? 1. Previous history of taking testosterone. 2. The client's mother having a history of breast cancer. 3. History of cirrhosis of the liver. 4. History of kidney disease. 5. History of radiation treatment for lung cancer.

Correct Answer: 2, 3, 5 Predisposing factors for breast cancer in the male population include radiation exposure, cirrhosis, estrogen medications, and a history of breast cancer in primary female relatives. Taking testosterone and kidney disease are not predisposing factors for male breast cancer.

The nurse is performing a breast assessment of an Asian adult female. Which action should the nurse complete first? 1. Ask the client if she has ever had any breast disease such as cancer of the breast, fibrocystic disease, or fibroadenoma. 2. Ask the client to disrobe from the waist up and place a gown on with the opening to the front. 3. Ask the client if she has noticed any changes in her breasts such as lumps, thickening, or discharge from the nipples. 4. Ask the client how she feels about her breasts.

Correct Answer: 3 Asking the client if she has noticed any changes in her breasts may open up rapport with this client. Females of Asian descent are often stoic and do not seek preventive care so this would be a good way to lead into the entire focus assessment and physical exam. Immediately asking her questions about breast disease, how she feels about her breasts, or having her disrobe would likely be uncomfortable for a client from this culture.

The nurse is teaching self-breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the nurse why this is necessary. Which response by the nurse is the most appropriate? 1. "It allows any masses to bulge forward to be seen." 2. "This is the only position to detect Paget's disease." 3. "This is the best position to look for skin dimpling." 4. "It is the only way to look for nipple retraction."

Correct Answer: 3 Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the client's arms over the head. Paget's disease is a rare type of breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction, does not have to be visualized with the arms over the head. Masses are rarely visible with inspection.

A pregnant client expresses concern about performing breast self-examination during pregnancy since her breasts are tender. Which response by the nurse is the most appropriate? 1. "All you need to do is just concentrate on having a healthy baby for now." 2. "You can wait until your breasts are no longer tender, and then resume your self-exams." 3. "It's very important for you to be familiar with the changes in your breasts." 4. "Breast cancer during pregnancy is rare, so don't worry about it."

Correct Answer: 3 During pregnancy, breast self-examination needs to be done and the procedure is the same, even though the breast tissue will be firmer, larger, and possibly more tender. Breast cancer needs to be identified as soon as possible and is treated on an individual basis. It may not be common for breast cancer to occur during pregnancy, but monitoring for it does need to continue. Therefore, self-breast examination must be implemented throughout the pregnancy and during lactation.

The nurse is teaching a client with benign breast disease about symptom relief. Which topic would the nurse include in this session? 1. Avoiding all fat in the diet. 2. Wearing a firm bra. 3. Limiting salt intake. 4. Drinking tea instead of coffee.

Correct Answer: 3 Symptom management includes such things as pharmacological hormones, diuretics, limiting caffeine, wearing a supportive bra, and decreasing salt intake, as these may help relieve symptoms of breast pain and tenderness, especially in the premenstrual period.

The nurse is educating a prenatal class about lactation when one of the clients asks how milk is produced. When responding to the client, which structure will the nurse include as being responsible for milk production? 1. Montgomery's glands. 2. Areola. 3. Acini cells. 4. Mammary ridge.

Correct Answer: 3 The acini cells are contained within the lobules that produce milk. The remaining structures are not responsible for milk production.

The nurse is performing a breast examination and is palpating into the tail of Spence. Why is it appropriate to palpate this area of the breast during an examination? 1. It does not contain any lymph nodes. 2. It can show the difference between fibrocystic disease and fibroadenomas. 3. Breast cancer occurs more frequently in this area. 4. Peau d'orange may occur in this area of the breast.

Correct Answer: 3 The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence. Masses in the tail must be distinguished from enlarged lymph nodes. It would be difficult to detect the difference between fibrocystic disease, breast cancer, and fibroadenomas by palpation alone—correlating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses. Peau d'orange and Paget's disease are changes in the breast skin and nipple area associated with forms of cancer.

During the breast examination on a client, the nurse palpates a small, subclavicular node on the right side of the client's chest. Which is the priority nursing action at this time? 1. Call the primary care provider. 2. Ask the client if they have a family history of breast cancer. 3. Continue with the exam. 4. Schedule a mammogram for the next available appointment.

Correct Answer: 3 Usually nodes are nonpalpable, but subclavicular nodes must be assessed as part of the examination. It would be important for the nurse to complete the exam in order to document size and location of any and all palpable masses. Documentation of the client's report to corroborate findings is also important. Reporting these findings in completeness to the primary care provider would be the next step, and any further follow-up would be determined by that provider, along with the client's input.

The mother of a late school-age female client voices concern to the nurse regarding her daughter's breast development and breast tenderness. Which response by the nurse is the most appropriate to the client's mother? 1. "I understand your concern. Your daughter is very young for breasts to be developing. Children this age are not equipped to deal with these changes." 2. "I will let her primary care provider know that an exam is necessary due to your daughter's symptoms." 3. "I wouldn't worry about it unless the tenderness continues or worsens." 4. "Breast enlargement and tenderness is common for children of this age, but I will inform her primary care provider of your concerns."

Correct Answer: 4 Breast enlargement and tenderness is common for children of this age, but I will inform her primary care provider of your concerns," is the best response because it directly answers the concerns of the mother with facts, and the primary care provider will be made aware of the situation.

The nurse is teaching a childbirth education class. When educating the participants about breast changes during pregnancy, which substance leaking from the breast is anticipated during pregnancy? 1. Blood. 2. Milk. 3. Serum. 4. Colostrum.

Correct Answer: 4 Colostrum is a form of milk produced by the mammary glands toward the end of pregnancy, and it is normal for some to leak from the nipples. Its appearance is a thick yellow discharge. The other options are not a normal occurrence at the end of a pregnancy.

A menopausal woman comes to the clinic with complaints of thin, watery nipple discharge with blood present. Based on this data, which disorder does the nurse suspect? 1. Mammary duct ectasia. 2. Fibrocystic disease. 3. Breast malignancy. 4. Intraductal papillomas.

Correct Answer: 4 Intraductal papillomas are the primary cause of nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women. Fibrocystic disease is first seen when women are in their twenties, and discharge may be straw-colored, clear, milky, or green. Discharge associated with mammary duct ectasia is thick and sticky. Malignancy that affects the nipple must be correlated with other physical findings, mammogram, and biopsy.

The nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant's nipple. Which conclusion by the nurse based on this data is the most appropriate? 1. The newborn has a congenital anomaly. 2. This is a highly irregular finding. 3. This is a reason to call in a specialist. 4. This is a common finding in a newborn.

Correct Answer: 4 The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy. Some infants may produce a thin discharge called "witch's milk," which subsides as the infant's body eliminates maternal hormones. This is neither irregular nor hereditary, and there is no reason to call on a specialist.

The nurse is evaluating the risk for metastasis after a client is diagnosed with breast cancer. Which lymph node involvement would indicate the greatest likelihood of metastasis for this client?

Correct Answer: B The internal mammary nodes drain toward the abdomen and the opposite breast. Most of the lymph from the rest of the breast drains toward the axilla and subclavicular region. Therefore, cancer within the breast can spread through the lymphatic system via the subclavicular nodes, into deep channels within the chest or abdomen, and even to the opposite breast.

The nurse is preparing a poster on self-breast examination and is labeling the anatomical structures of the breast. Which location will the nurse use to identify the tail of Spence?

Correct Answer: B The tail of Spence, also called the axillary tail, is the portion of breast tissue that expends superiolaterally into the axilla.