Chapter 20: Assessing Breasts and Lymphatic System Combined (Final)

During the physical examination of a client, a nurse notes that the client has tenderness of the breasts. Which question should the nurse ask the client with regard to this finding?

"Are you taking oral contraceptive pills?" Explanation: The nurse should question the client on the use of oral contraceptives as they can cause breast tenderness due to hormonal effect. Questioning the client about family history, past history, and habits such as drinking and smoking are not related to finding tenderness of the breasts.

Mrs. Ash, a client in her 50s, has told the nurse during her most recent visit to the clinic that she and her circle of friends have discontinued breast self-examination (BSE) since hearing and reading that the practice is now considered ineffective. How can the nurse best respond to Mrs. Ash?

"BSE is certainly not a replacement for other screening methods, but a high proportion of breast masses are in fact detected by women themselves." Explanation: While BSE does not reduce breast cancer mortality, the fact remains that a high proportion of breast masses are detected by women themselves. BSE should be coupled with mammography and clinical examination.

The client reports to the nurse that she is concerned she has cancer as she has been experiencing clear discharge from her breasts. What is the best response of the nurse?

"Do you take any medications?" Explanation: Some medications such as steroids, calcium channel blockers, oral contraceptives. or tranquilizers may also cause nipple discharge. Stress, family history and early pregnancy do not cause clear discharge.

A middle-aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be and asks what might be causing this. What is an appropriate response by the nurse?

"Firmness of the breasts decreases with age as estrogen levels decrease." Explanation: A decrease in the size and firmness of the breasts is common as women age because of the decrease in estrogen levels. A well-fitting bra will help with sagging, but this statement does not answer the client's question as to why it is happening. Prior pregnancies are not a factor in the firmness of breast tissue. Estrogen replacement therapy will not reverse or stop the process.

The client tells the nurse that she has benign breast disease and so she is not worried about any lumps or nodules in her breasts. How would the nurse best respond?

"It is important to perform self breast examinations as there could be changes or additional lumps in your breasts that would need further examination." Explanation: Benign breast disease can mask cancer so if is important the client perform self breast examinations to identify any changes or additional lumps to identify any changes early.

Nurse G. is conducting a teaching session on breast self-examination to a group of women at a health fair sponsored by the local community center. Which of the following instructions is most accurate?

"Remember that doing BSE regularly is not a replacement for regularly-scheduled mammograms or clinical examinations." Explanation: BSE should be coupled with mammography and clinical examination on a schedule congruent with current guidelines and the client's risk factors. It should be performed 5 to 7 days after the beginning of the woman's period and all lumps or changes should be followed up. A standing position in the shower is appropriate for palpation.

A client asks why the nurse touches the area near the arm pit when conducting a breast examination. What should the nurse respond to this client?

"The upper outer quadrant of the breast extends into the axillae." Explanation: The upper outer quadrant extends into the axillary area and is referred to as the tail of Spence. This is the location for most breast tumors. The mammary ducts are located closer to the glandular tissue. The fibrous tissue provides support for the glandular tissue. Fatty tissue provides most of the substance of the breast.

The client tells the nurse "I am so glad I had a mastectomy and I will never have breast cancer again." How should the nurse best respond?

"We need to continue to perform examinations. Breast cancer can reoccur." Explanation: Breast cancer can reoccur at the scar site or in other areas of the breast. The client is at no higher risk because of a diagnosis of breast cancer. It is up to the client if she wishes to share her diagnosis with others.

An older female client states she is upset about her sagging breasts. She states, "I know it's because I haven't been sexually active since my husband died and my hormones are all dried up." What is the nurse's best response?

"What you're experiencing is an expected effect of the aging process." Explanation: The suspensory ligaments relax, causing breasts to sag and droop. Breasts also decrease in size and lose elasticity. Nipples become smaller, flatter, and less erectile. Axillary hair may stop growing at this time. These changes are more apparent in the eighth and ninth decades of life. The client's concern is the physical change of sagging breasts, not meeting men. Sagging breasts are expected changes; hormone therapy is

When should a woman conduct self breast examination with respect to her menses?

5 to 7 days following her menses Explanation: The breast examination should be conducted during the time with the least estrogen stimulation of the breast tissue. This corresponds to 5 to 7 days following menses.

When would be the best time during the month for a post-menopausal woman to perform self-breast examination?

A convenient day of each month Explanation: With the cessation of menses, hormonal changes no longer affect the breasts. For this reason, clients can choose a convenient day of each month to perform SBEs. With this information, none of the other options present the best time.

A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?

A recently retracted nipple that was previously everted Explanation: A recently retracted nipple that was previously everted suggests malignancy. Normal findings include nipples being nearly equal in size and in the same location on each breast. Nipples are usually everted, but they may be inverted or flat. Supernumerary nipples may appear along the embryonic "milk line."

A 23-year-old computer programmer comes to the office for an annual examination. She has recently become sexually active and wants to start oral contraception. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt; she scrubs her skin nightly with soap and water, but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The client denies tobacco but drinks four to five drinks on Friday and Saturday nights. She denies any illegal drug use. Examination shows a mildly obese woman breathing comfortably. Her vital signs are unremarkable. Inspection of the axillae reveals dark velvet-like skin. Her annual examination is otherwise unremarkable. What disorder of the breast or axilla is she most likely to have?

Acanthosis nigricans Explanation: Acanthosis nigricans can be associated with an internal malignancy, but in most cases it is a benign dermatological condition associated with polycystic ovarian syndrome, a syndrome consisting of acne, hirsutism, obesity, irregular periods, infertility, ovarian cysts, and early onset type 2 diabetes. It is also known to correlate with insulin resistance.

The nurse reviews factors related to which of the following areas to assess a client's risk of breast cancer?

Age, family history, reproductive history Explanation: While numerous risk factors have been identified for breast cancer, age, family history, and reproductive history are among the most significant.

A client denies performing breast self-examination however practices breast awareness. What is this client focusing on when following this practice?

Appearance, feel, and shape of the breasts and nipples Explanation: Because breast self-examination has been met with controversy, an alternative called breast self-awareness may be practiced. This is the act of becoming familiar with the appearance, feel, and shape of one's breasts and nipples. Breast self-awareness does not focus on the size of the chest and bra or the amount of breast discomfort with menstruation. Discharge from the nipples should be reported to the health care provider for evaluation.

A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the other. Which action should the nurse take next?

Ask the client whether the larger breast has increased in size recently Explanation: Breasts can be a variety of sizes and are somewhat round and pendulous. One breast may normally be larger than the other. However, a recent increase in the size of one breast may indicate inflammation or an abnormal growth; it thus would be best for the nurse to inquire about any recent changes in breast size. There is no need to inform the physician immediately. Inquiring about the client's family history of breast cancer should have occurred earlier, during the interview.

A client who recently received breast implants asks for recommendations on performing breast self-examination (BSE). Which of the following should the nurse mention? Select all that apply.

Ask the surgeon to help her distinguish the implant from her breast tissue. Press firmly inward at the edges of the breast implants to feel the ribs beneath. Explanation: If the client has breast implants, she may perform breast self-examination monthly on the implanted breast. To do this effectively, she should ask her surgeon to help her distinguish the implant from her breast tissue. She should press firmly inward at the edges of the breast implants to feel the ribs beneath, checking for any lumps or bumps. However, she should be careful not to manipulate (i.e., squeeze) the valve on the implant excessively, which may cause valve leakage and make the breast implant deflate.

The nurse instructs a female client on breast self-examination. Which part of the breast should the nurse explain as being the area where most cancers occur? Select the part on the diagram.

The upper outer quadrant is the area most targeted by breast cancer.

While assessing an adult woman new to the clinic, the nurse should perform a subjective assessment of what risk factors?

Bottle fed all three children Explanation: Some risk factors that the nurse assesses during subjective data collection are a family history of breast cancer in first-degree relatives (client's mother and grandmother), early onset of

A 63-year-old nurse comes to the office upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-breast examinations. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-pack a year history. She denies any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. Examination shows an older woman appearing her stated age. Visual inspection of her right axilla reveals nothing unusual. Palpation reveals a 2-cm hard fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of the right breast, the nurse detects a nontender 1-cm lump in the tail of Spence. What disorder of the axilla is most likely responsible for her symptoms?

Breast cancer Explanation: Metastatic lymph nodes tend to be hard, nontender, and fixed, often to the rib cage. Although the client has no family history of breast cancer, she is at a slightly increased risk because she never had children.

A 72-year-old retired saleswoman comes to the office with a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The client denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetrical with no skin changes. The nurse can express bloody discharge from the client's left nipple. No discrete masses are palpable, but her left axilla has a hard 1-cm fixed node. The remainder or her heart, lung, abdominal, and pelvic examinations are unremarkable. What is the most likely cause of nipple discharge in her circumstance?

Breast cancer Explanation: Nipple discharge in breast cancer is usually unilateral and can be clear or bloody. Although a breast mass is not palpated, in this case a fixed lymph node is palpated. Other forms of breast cancer can present as a chronic rash on the breast.

Which type of discharge should a nurse consider normal with palpation of the nipples during a breast examination of a nonlactating female client?

Clear Explanation: A clear discharge is a normal finding that may be obtained on manual expression from a breast that is frequently stimulated. Milky discharge, blood-tinged discharge, and discharge from one breast are abnormal findings in this examination. A milky discharge is normal only during pregnancy or lactation. A client with any blood or blood-tinged discharge should be referred to a physician for further evaluation. Discharge from one breast may indicate benign intraductal papilloma, fibrocystic disease, or cancer of the breast.

The nurse is examining the breast of a clinic client and palpates a lump. What would the nurse be sure to document about this lump? Select all that apply.

Consistency Distinctness Mobility Explanation: If a lump is palpated, the nurse documents the location, size, shape, consistency, mobility, tenderness, and distinctness. Additionally, the nurse notes the skin over the lump, the nipple, and any lymphadenopathy. The nurse would not note erythema or pallor of the lump, because these are notations about the skin over the lump.

Fibrous tissue that provides support for the glandular tissue of the breasts is termed

Cooper ligaments. Explanation: The fibrous tissue provides support for the glandular tissue largely by way of bands called Cooper's ligaments (suspensory ligaments). These ligaments run from the skin through the breast and attach to the deep fascia of the muscles of the anterior chest wall.

A 48-year-old woman has presented to her primary care provider concerned about the recent detection of a mass in her left breast. The mass is tender on palpation, and the nurse notes that it is round, well-delineated, and mobile. There is no evidence of nipple retraction on inspection. Which of the following breast masses would the nurse first suspect?

Cyst Explanation: Cysts are typically tender, mobile, and well-delineated and usually occur in women age 30-50. Retraction signs are normally absent.

While interviewing a 23-year-old client, a nurse discusses the need for a clinical breast examination (CBE). How often should this client be receiving a CBE?

Every 3 years Explanation: The ACS recommends a clinical breast examination (CBE) by a health care professional every 3 years for women ages 20 to 39 and every year for women age 40 and older.

Inspection of the breast is done with the client in a supine position.

False Explanation: The breasts are first inspected in the sitting position while the client is asked to hold arms in different positions. The breasts are then palpated while the client assumes a supine position.

During the breast examination of a client, the nurse notes firm but rubbery lesions in both breasts. The client comments that the lesions become tender just before menses. The nurse understands that these symptoms are most likely due to which breast condition?

Fibrocystic lesions Explanation: Fibrocystic lesions are benign and firm but rubbery lesions that tend to be bilateral and may become tender just before menses. Paget's disease causes red, scaly, and crusty areas over the areola. A pigskin-like or orange-peel appearance is found in metastatic disease of the breast. It results from edema caused by blocked lymphatic drainage. A fibroadenoma is a round, firm, and well-defined mass, is seldom tender, and is usually singular and mobile.

Which technique is appropriate for the nurse to use to palpate a client's breast?

Flat pads of three fingers Explanation: The nurse should use the flat pads of three fingers to palpate the breast of the client for accurate assessment. The tips of four fingers, palms of both hands, or palm and fingers of one hand are not used for assessing the breasts as they may not give accurate results on examination.

While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that she recently had a baby and is currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production?

Glandular Explanation: Glandular tissue constitutes the functional part of the breast, allowing for milk production. The fibrous tissue provides support for the glandular tissue largely by way of bands called Cooper's ligaments (suspensory ligaments). Fatty tissue provides most of the substance to the breast and thus determines the size and shape of the breasts. Lymphatic tissue, which forms lymph nodes, is responsible for draining lymph from the body.

The nurse is assessing a 15 year old male and finds soft, fatty enlargement of breast tissue. The nurse would document this as what?

Gynecomastia Explanation: Gynecomastia is breast enlargement. Cysts are lumps that may be found in the breasts. Abscesses are an infection. Fibroadenoma is a well-defined , usually single or multiple, nontender, firm or rubbery, round or lobular mass that is freely movable.

When preparing a teaching session for women about breast cancer, the nurse should include information about which modifiable risk factor(s)? Select all that apply.

Having no children Postmenopausal hormone therapy Obesity Physical inactivity Explanation: Modifiable risk factors (lifestyle factors) for breast cancer for women include having no children, having children after the age of 30, postmenopausal hormone therapy, obesity, and physical inactivity. Oral contraceptive use, breastfeeding, and alcohol use are also lifestyle risk factors. Gene mutations are nonmodifiable risk factors of breast cancer.

While interviewing a client, the nurse asks her what her typical daily diet consists of. Which of the following is associated with an increased risk for breast cancer?

High-fat diet Explanation: A high-fat diet may increase the risk for breast cancer. Alcohol intake exceeding two drinks per day and tobacco use has been associated with a higher risk for breast cancer. Caffeine can aggravate fibrocystic breast disease, but is not associated with breast cancer. A high-sugar diet is not associated with breast cancer.

A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. Examination shows a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia?

Imbalance of hormones of puberty Explanation: Approximately one-third of teenage boys develop gynecomastia during puberty. It is not surprising that the two older brothers did not have this.

The nurse notes that a client's left breast feels significantly warmer than the right breast. What should the nurse consider is occurring with this client?

Inflammation Explanation: Heat in the breasts of a client who has not given birth or lactating indicates inflammation. This finding is not associated with breast cancer or fibrocystic breast disease. Extramammary ducts are visible and not associated with warmer skin temperature over the breast.

A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Mark all that apply.)

It is important to guide clients through self breast examination that emphasizes timing, inspection, and palpation. Pain and pallor are not emphasized when teaching self breast examination.

The nurse instructs a female client on breast self-examination. Why does the nurse recommend the pattern shown for the client to use?

It is the best technique to detect masses Explanation: The vertical stripping pattern is currently the best validated technique for detecting breast masses. It is not recommended because it takes the least amount of time, is the easiest for the client to learn, or because it causes the least amount of pain.

The nurse plans to instruct an adult female client with regular menstrual cycles, who is not taking oral contraceptives, about breast self-examination. The nurse should plan to instruct the client to perform breast self-examination

right after menstruation. Explanation: BSE is usually performed monthly after the period.

When examining the breasts of a client, the nurse finds a collection of fatty tissue that appears as a lump. The nurse knows that this is which of the following conditions?

Lipoma Explanation: Lipomas are a collection of fatty tissue that may also appear as a lump. Milk cysts are sacs filled with milk. Fibroadenomas are usually 1-5 cm, round or oval, mobile, firm, solid, elastic, nontender, single or multiple benign masses found in one or both breasts. Malignant tumors, or carcinomas, are most often found in the upper outer quadrant of the breast. They are usually unilateral, with irregular, poorly delineated borders. They are hard and nontender and fixed to underlying tissues.

A female client asks what can be done to reduce the risk of developing breast cancer. What instruction should the nurse provide this client? Select all that apply.

Maintain a normal body weight. Limit alcohol use. Breastfeed infants. Exercise. Explanation: Modifiable risk factors for breast cancer include avoiding menopausal obesity and limiting alcohol intake. Breastfeeding a child can decrease the client's risk for breast cancer. Physical inactivity can increase the client's risk for breast cancer. Mammograms should be performed according to the American Cancer Society and may differ according to the client's age.

During the breast examination of a client, the nurse notes an orange-peel or "peau d'orange" appearance of the skin of the breast. The nurse understands that this appearance of the skin is due to what type of breast condition?

Metastatic disease Explanation: A pigskin-like or orange-peel appearance is found in metastatic disease of the breast. It results from edema caused by blocked lymphatic drainage. Fibroadenoma, benign disease, and infection do not cause orange-peel appearance of the skin. Fibrocystic lesions are benign and firm but rubbery lesions that tend to be bilateral and may become tender just before menses. Paget's disease causes red, scaly, and crusty areas over the areola.

During the physical examination, a nurse palpates the breasts of a client for masses. The nurse knows that if the client has benign breast disease, masses with which characteristics will be present? (Select all that apply.)

Multiple rubbery mobile nodules with well-demarcated borders are found in benign breast disease. Malignant tumors are hard and nontender and fixed to underlying tissues. They are usually unilateral with irregular and poorly delineated borders.

A 56-year-old woman comes to the clinic reporting that her left breast looks unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-breast examinations so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and drinks three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy, but her father died of prostate cancer. Examination shows a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating towards the lateral side. On palpation the nipple feels thickened. Lateral to the areola is a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast examination and axilla are unremarkable. What visible skin change of the breast does she have?

Nipple retraction Explanation: A retracted nipple is flattened or pulled inward or toward the medial, lateral, anterior, or posterior side of the breast. The surrounding skin can be thickened. This is a relatively late finding in breast cancer.

When inspecting the nipples, which of the following findings is unexpected?

Retraction of the left nipple Explanation: Longstanding nipple inversion and supernumerary nipples do not constitute threats to health. A downward point of the nipples, provided symmetry exists, is not necessarily pathological, while retraction can indicate underlying cancer.

When palpating a breast, what must the nurse examine the breast tissue carefully for? (Select all that apply.)

Nodules Tenderness Consistency Explanation: Examine the breast tissue carefully for consistency of the tissues, tenderness, and nodules.

What is considered a modifiable risk factor for breast cancer?

Obesity Explanation: It is important for women to be aware of their specific risk factors for breast cancer. A modifiable risk factor for breast cancer is obesity. Asthma is not correlated with breast cancer. Genetics and age are not modifiable risk factors.

Which of the following assessment findings is most likely benign on breast examination?

One breast larger than the other Explanation: Asymmetry in size of the breasts is a common benign finding. The others are concerning for underlying malignancy.

During a breast assessment the nurse finds scaly lesions at the nipple with a lump behind the nipple. The nurse suspects what?

Paget disease Explanation: A rash or ulceration may occur in Paget disease. Peau d'orange has an orange peel appearance and is caused by breast edema from blocked lymph drainage and indicates advanced cancer. Erythema is redness and hyperpigmentation is a darker area.

During the breast examination of a client, the nurse notes red, scaly, and crusty areas over the areola. The nurse understands that this appearance of the skin is due to what type of breast condition?

Paget disease Explanation: Paget disease causes red, scaly, and crusty areas over the areola. A pigskin-like or orange-peel appearance is found in metastatic disease of the breast. It results from edema caused by blocked lymphatic drainage. A fibroadenoma is a round, firm, and well-defined mass, is seldom tender, and is usually singular and mobile. Fibrocystic lesions are benign and firm but rubbery lesions that tend to be bilateral and may become tender just before menses.

When performing a breast assessment on a clinic client, the nurse practitioner notes scaly lesions that begin at the nipple and move toward a lump behind the nipple well. The NP would know that further assessment for what would be necessary?

Paget's disease Explanation: Paget's disease produces scaly lesions that begin at the nipple and progress to a lump behind the nipple well. Severe pain (mastalgia) is more likely to result from trauma or infection. Single breast masses can indicate benign conditions (e.g., cysts, fibroadenoma, fat necrosis, lipoma) or more serious conditions (e.g., cancer).

A 44-year-old woman comes to the clinic complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-breast examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. Examination shows a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath a nontender 2-cm mass is palpable. The axilla contains only soft moveable nodes. The left breast examination and axilla are unremarkable. What visible skin change of the breast does she have?

Paget's disease Explanation: This uncommon form of breast cancer starts as an eczema-like scaly skin change around the areola. The lesion may weep, crust, or erode. It can be associated with an underlying mass, but the skin change can also be found alone. Any eczema-like area around the nipple that does not respond to topical treatment needs to be evaluated for breast cancer.

A mother brings her adolescent son into the clinic because she is concerned about his development of breast tissue. Her son denies use of any medications and is slender in appearance. What should be the nurse's next action?

Palpate for any irregular or hard masses. Explanation: Gynecomastia (firm, glandular tissue in the breasts) in males may occur when there is an imbalance of estrogen and androgen. An ulcer or hard, irregular mass suggests cancer and should be palpated for upon initial assessment. Gynecomastia also occurs with use of anabolic steroids, diseases, and as an adverse effect of some medications; however this boy denies any medication use. Gynecomastia also occurs in overweight or obese males; however this client is slender; therefore dietary teaching is not the next, best action. These hormonal changes can be expected; but first the nurse should assess for a serious condition such as cancer by palpating for hard or irregular masses. Uncomplicated gynecomastia does tend to resolve with time; but the nurse must assess for signs of abnormalities such as cancer first.

A nurse is examining the breasts of a woman who has had a mastectomy. Which of the following should the nurse do?

Palpate the scar for redness, lesions, lumps, swelling, or tenderness Explanation: If the client has had a mastectomy or lumpectomy, it is still important to perform a thorough examination. Palpate the scar and any remaining breast or axillary tissue for redness, lesions, lumps, swelling, or tenderness. White scar tissue in a client who underwent a mastectomy or lumpectomy is a normal finding and need not be referred.

The nurse instructs a client on breast self-examination techniques. Which observation indicates that teaching has been effective?

Palpates the breasts using an up and down approach Explanation: When performing a breast self-examination, the client should be supine with the arm of the breast being examined under the head. The breasts should be palpated with the fingertips. The arms should be placed on the hips or extended above the head. One approach to palpate the breasts is to use an up and down approach.

A nurse is discussing breast self-examination (BSE) with a 60-year-old woman. Which of the following should the nurse recommend?

Picking a set day of the month that the client will remember on which to perform BSE Explanation: Older clients and others who no longer menstruate may find it helpful to pick a set day of the month for BSE, a date that they will remember each month such as the day of the month they were born. Although BSE is not required, the nurse should not encourage the client to discontinue it if she is already performing it. It is unlikely that the client is still menstruating at her age. The BSE, if performed, should be done monthly, not annually.

A nurse is examining the breasts of a 75-year-old woman. Which of the following are normal findings in the breasts of an older adult? Select all that apply.

The older client often has more pendulous, less firm, and saggy breasts and smaller, flatter nipples that are less erectile on stimulation. Peau d'orange skin, associated with carcinoma, and spontaneous discharge are not normal findings in the breasts of older adults and should be referred for further evaluation.

A nonpregnant female presents to the health care facility and reports new onset of breast discharge. The nurse assesses the discharge to be milky in appearance without breast tenderness or masses. What additional data should the nurse obtain from this client?

Prescribed medications such as antipsychotic agents Explanation: A persistent milk secretion (galactorrhea) from the breasts in a nonpregnant, nonlactating woman can be caused by the intake of hormones, contraceptives, and some antipsychotic agents, such as haloperidol (Haldol). Recent surgeries or trauma and exposure to chemicals are not known to cause persistent milk discharge. Excessive alcohol intake is a risk factor for the development of breast cancer.

During the physical examination of a client's breast, which finding should the nurse recognize as a possible indication of a malignant tumor?

Retraction of nipples Explanation: Retracted nipples are indicative of a malignant tumor. A malignant tumor has fibrous strands attached to the breast tissue and the fascia of the muscles. As the muscle contracts, it draws the breast tissue and skin with it, causing dimpling or retraction. Lumps are ill defined and nontender in breast cancer. Linear stretch marks may be seen during and after pregnancy or with significant weight gain or loss. A generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications.

A nurse examines a client diagnosed with fibroadenoma. Which characteristic of the lump should the nurse expect to find in the client?

Round, firm, well-defined Explanation: The nurse should expect to find a round, firm, and well-defined mass in a client with fibroadenoma. Fibroadenomas are lobular, ovoid, or round. They are firm, well-defined, seldom tender, and usually singular and mobile. An irregular, hard, not well-defined mass is characteristic of a cancerous tumor. Fibroadenomas are round and well-defined but not elastic. A tender, mobile, well-defined mass characterizes benign breast disease.

When palpating the female breast for masses, the nurse distinguishes which of the following characteristics as a potentially cancerous mass?

Single, firm, fixed nodule Explanation: Any mass that is firm, fixed, poorly circumscribed, and qualitatively different from surrounding tissue strongly suggests cancer.

A nurse should ask a client to assume which position to begin the examination of the breasts?

Sitting Explanation: Inspection is the first physical assessment technique. A breast exam should begin with the client in a sitting position with arms hanging loosely at the sides to inspect for breast size and symmetry. Palpation of the breasts requires the client to lie down. Breasts are not percussed.

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about this lump?

Size Explanation: When palpating a breast lump, the nurse documents the lump's location, size, shape, consistency, mobility, tenderness, and distinctness. The nurse would not note pallor of the lump—that finding relates to the skin over the lump. Nipple size and chest symmetry are not directly related to the lump in question.

What can the nurse recommend to a young female client who is seeking to reduce her risk for breast cancer? Select all that apply.

Strenuous exercise, pregnancy before 30 years of age, and breast-feeding are factors that help to reduce the risk for breast cancer. Intake of a high fat diet and consumption of alcohol (especially 2-5 or more drinks daily) are both possible risk factors for the development of breast cancer.

A client is concerned about a dark skin lesion on her anterolateral abdomen. The lesion has not changed, nor is there any discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?

Supernumerary nipple Explanation: This represents a supernumerary nipple. These occur along the "milk line" and do not exhibit features of more concerning lesions.

When examining the male breast, for what does the nurse inspect? Select all that apply.

Swelling of the nipple Ulceration of the areola Nipple drainage Explanation: Examining the male breast involves inspecting the nipple and areola for swelling, ulceration, or drainage. Additionally, the nurse palpates the areola and breast tissue for nodules or masses. When looking for a possible breast mass, even in a male, it is done by palpation, not inspection.

Which is true of women who have had a unilateral mastectomy?

They should be examined carefully along the surgical scar for masses. Explanation: A woman who has had breast cancer remains at high risk for recurrence, especially in the contralateral breast. The mastectomy site should be carefully examined for local recurrence as well. Lymphedema or swelling of the ipsilateral arm following mastectomy is common and does not usually indicate recurrence. Women with breast reconstruction must also undergo careful examination.

How should a nurse instruct a client to perform a breast self-examination to most effectively cover the entire breast?

Up-and-down pattern starting at the underarm and moving across the breast Explanation: There is some evidence that the up-and-down pattern, also referred to as the vertical pattern, is the best method to most effectively cover the breast tissue. It is important to teach the client that breast tissue covers the entire upper chest, thus the exam should be performed from the underarm and move across the breast to the middle of the chest bone (sternum). Hands should go up and down the breast until the client feels the ribs and up to the neck area.

A nurse is examining the breasts of a client. In which quadrant should the nurse most expect to find a tumor?

Upper outer quadrant Explanation: The upper outer quadrant, which extends into the axillary area, is referred to as the tail of Spence. Most breast tumors occur in this quadrant.

The American Cancer Society currently recommends that palpation of the breast be done in what pattern?

Vertical Explanation: Various techniques for palpation can be performed. The ACS (2014) currently recommends using the vertical pattern because some evidence supports that this is the most effective means of examining the entire breast.

The nurse is preparing to conduct a clinical breast examination of a client. Current recommendation suggest that which pattern should be followed when assessing the breast tissue?

Vertical strip Explanation: The vertical strip pattern is currently the best validated technique for detecting breast masses. The circular or wedge pattern can be used but it is not the best validated technique for detecting breast masses. The concentric circle pattern is used to palpate at each examination point during the breast examination.

What pattern of palpation is currently the best validated technique for detecting breast masses?

Vertical strip pattern Explanation: Although a circular or wedge pattern can be used, the vertical strip pattern is currently the best validated technique for detecting breast masses.

Which client is at greatest risk for the development of a cancerous breast lesion?

a 60-year-old postmenopausal woman Explanation: Breast cancer is most observable in women over the age of 50. Age-related risks for cysts are higher in women over 50 on estrogen therapy. The risk for fibroadenoma is higher for women between ages 15 to 25 but can be seen in women up to about age 55.

The nurse is preparing to examine the breasts of a female client who had a left radical mastectomy 3 years ago. When examining the client, the nurse observes redness at the scar area. The nurse should explain to the client that this may be indicative of

an infectious process. Explanation: Redness and inflammation of the scar area may indicate infection.

The nurse observes an orange peel appearance, or peau d'orange, of the areolae of a client's breasts. The nurse should explain to the client that this is most likely due to

blocked lymphatic drainage. Explanation: A pigskin-like or orange-peel (peau d'orange) appearance results from edema, which is seen in metastatic breast disease. The edema is caused by blocked lymphatic drainage.

The nurse is working with a community group to set up teaching programs to increase awareness among African American women about preventive screening techniques for breast cancer. In the teaching program, the nurse should plan to include

breast cancer clients of the same race. Explanation: Black women were found to have various perceptions on the risks of breast cancer related to existing knowledge stigmatization, as well as spiritual and religious beliefs, which can decrease their engagement in breast cancer screening.

The nurse is conducting a breast examination. Which nodes should the nurse expect to be palpable?

central Explanation: Lymphatics from most of the breast drain toward the axilla. Of the axillary lymph nodes, the central nodes are most frequently palpable. The other groups of nodes are seldom palpable and include the lateral, pectoral, and subscapular nodes.

The nurse is caring for an adult female client when the client tells the nurse that she has had a clear discharge from her nipples for the past month. The nurse should ask the client if she has been taking

contraceptives. Explanation: Discharge may be seen in endocrine disorders and with certain medications (i.e., antihypertensives, tricyclic antidepressants, and estrogen).

The nurse is assessing an adult male client when the nurse observes gynecomastia in the client. The nurse should ask the client if he is taking any medications for

depression. Explanation: Gynecomastia, a smooth, firm, movable disc of glandular tissue, may be seen in one breast in males during puberty, usually temporary. However, it may also be seen in hormonal imbalances, drug abuse, cirrhosis, leukemia, and thyrotoxicosis. Irregularly shaped, hard nodules occur in breast cancer.

The nurse is concerned that a client has undiagnosed cancer of the breast. What assessment finding is most likely related to this clinical determination?

dimpling of the breast Explanation: Dimpling could indicate an underlying lesion that causes the tissue to pucker with movement. Uneven breast size is not an indication of breast cancer. Retracted nipples do not indicate breast cancer unless it is a new finding and occurs in one breast. Uneven areola size is not an indication of breast cancer.

A client has had a recent mastectomy and visits the clinic for postoperative evaluation. The client tells the nurse that she has been depressed and feels as if she is less of a woman. The most appropriate nursing diagnosis for this client is

disturbed body image related to mastectomy. Explanation: When interviewing clients—especially females—about the breasts, keep in mind that this topic may evoke a wide spectrum of emotions from the client. Explore your own feelings regarding body image, fear of breast cancer, and the influence of the breasts on self-esteem. Disturbed body image is the most appropriate nursing diagnosis.

The size and shape of the breasts in females are related to the amount of

fatty tissue. Explanation: Fatty tissue is the third component of the breast. The glandular tissue is embedded in the fatty tissue. This subcutaneous and retromammary fat provides most of the substance to the breast, determining the size and shape of the breasts.

A female client tells the nurse that her breasts become lumpy and sore before menstruation but get better at the end of the menstrual cycle. The nurse should explain to the client that these symptoms are often associated with

fibrocystic breast disease. Explanation: Lumps may be present with benign breast disease (fibrocystic breast disease), fibroadenomas, or malignant tumors. Premenstrual breast lumpiness and soreness that subside after the end of the menstrual cycle may indicate benign breast disease (fibrocystic breast disease).

Benign conditions of the breast include

fibrocystic changes Explanation: Cysts (due to BBD) are common lumps that are usually elliptical or round, soft, and mobile. Size may vary, and they often occur in multiple numbers, usually in both breasts, and frequently in the upper outer quadrants.

Which characteristic would support the determination that a client is at high risk for breast cancer?

first degree relative with a history of either BRCA1 or BRCA2 mutation Explanation: A known first-degree relative, including a father or brother, with BRCA1 or BRCA2 mutation is considered a high risk factor for the development of breast cancer. The remaining options are associated with a moderate risk.

The functional part of the breast that allows for milk production consists of tissue termed

glandular. Explanation: Glandular tissue constitutes the functional part of the breast, allowing for milk production. Glandular tissue is arranged in 15 to 20 lobes that radiate in a circular fashion from the nipple. Each lobe contains several lobules in which the secreting alveoli (acini cells) are embedded in grape-like clusters.

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs further instructions when the student says that one risk factor is

having a baby before the age of 20 years. Explanation: Having a baby before 20 years of age does not increase the risk of breast cancer. The risk of breast cancer is greater for women who have never given birth or for those who had their first child after age 30. A family history of breast cancer, consumption of a high-fat diet, and late menopause are all factors that increase the risk of breast cancer.

The lymph nodes that are responsible for drainage from the arms are the

lateral lymph nodes. Explanation: The lateral nodes drain most of the arms.

At puberty, the female breasts enlarge in response to estrogen and

progesterone. Explanation: The male and female breasts are similar until puberty, when female breast tissue enlarges in response to the hormones estrogen and progesterone, which are released from the ovaries.

What instruction should the nurse provide to a client to assess for dimpling or retraction of breast tissue?

raise arms over the head Explanation: To bring out dimpling or retraction that may otherwise be invisible, ask the client to raise the arms over the head. Shrugging the shoulders, bending the arms at the elbows, and extending the arms out to the side are not actions to bring out breast dimpling or retractions.

The nurse is assessing a 50-year-old client's breasts and observes a spontaneous discharge of fluid from the left nipple. The nurse should

refer the client for a cytology examination. Explanation: Any type of spontaneous discharge should be referred for cytologic study and further evaluation.

A nurse teaches a client about breast self-examination. What should the nurse tell the client about examining the underarm? The arm should be:

slightly raised Explanation: When performing an underarm examination during breast self-examination, the nurse should tell the client to keep the arm slightly raised up. Raising the arm straight up tightens the tissue in the area and makes it very difficult to examine. The examination may not yield accurate results if the arms are straightened up, kept on the hips, or kept at 90 degrees.

The nurse instructs the client to lean forward so she can inspect the breasts. What might this position reveal that is not visible in another position?

symmetry of the breast or nipple Explanation: This position may reveal an asymmetry of the breast or nipple not otherwise visible.

The nurse observes dimpling in an adult female client's breasts. The nurse should explain to the client that dimpling of the breast may indicate a

tumor. Explanation: Dimpling or retraction is usually caused by a malignant tumor that has fibrous strands attached to the breast tissue and the fascia of the muscles. As the muscle contracts, it draws the breast tissue and skin with it, causing dimpling or retraction.

After assessing the breasts of a female client, the nurse should explain to the client that most breast tumors occur in the

upper outer quadrant. Explanation: The upper outer quadrant, which extends into the axillary area, is referred to as the tail of Spence. Most breast tumors occur in this quadrant.