ATI Health Assess 2.0: Breast and Lymphatics

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse can see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the client's lymph node enlargement? A. A supernumerary nipple B. Infection C. Increased adipose tissue D. Psychotropic medication use

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

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple? A. A client reports recent serosanguinous nipple discharge B. A client reports that one nipple has begun to point in a different direction C. A client's nipple has remained inverted since childhood D. A client's nipple has a small crust present on the tip

C. A client's nipple has remained inverted since childhood Rationale: The nurse should include nipple inversion since puberty as an example of an expected variation in breast appearance. Nipples are inverted at birth and usually begin to protrude during puberty.

A nurse is performing a breast examination on a client and notices that the client's right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition? A. Adverse effect of beta-blocker medication B. Recent onset of menopause C. Arterial occlusion on the right side D. Recent surgery on the right side

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

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the client's past health history? Select all that apply. A. "Have you ever had breast disease?" B. "Have you experienced breast trauma?" C. "Have you had breast surgery?" D. "Do you perform breast self-examinations?" E. "Has anyone in your family had breast cancer?"

Rationale: "Have you ever had breast disease?" is correct. The nurse should ask whether the client has ever had breast disease, such as fibrocystic disease or cancer, while obtaining the client's past health history. "Have you experienced breast trauma?" is correct. The nurse should ask whether the client has ever experienced breast trauma while obtaining the client's past health history. "Have you had breast surgery?" is correct. The nurse should ask the client whether they have had breast surgery while obtaining the client's past health history. Breast surgery can cause atypical hyperplasia of breast tissue, which increases the risk for breast cancer. "Do you perform breast self-examinations?" is correct. The nurse should ask whether the client performs breast self-examinations while obtaining the client's past health history. It is important for the client to perform breast self-examinations to increase the chance for early detection of a lump.

A nurse is teaching a group of newly licensed nurses about routine mammography screenings for female clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. "A 55-year-old client should receive mammography screenings at least every 2 years." B. "Clients can discontinue routine mammography screenings when they are 65 years old." C. "Clients should begin routine mammography screenings when they are 35 years old." D. "A 45-year old client should receive mammography screenings at least every 5 years."

A. "A 55-year-old client should receive mammography screenings at least every 2 years." Rationale: Mammography guidelines recommend routine mammography screenings every 1 to 2 years for female clients between 40 to 75 years old. Therefore, this statement indicates an understanding of the teaching.

A nurse is reviewing breast self-examination techniques with a client. Which of the following client statements indicates an understanding of the techniques? A. "I will use circular motions to feel the texture of my breast tissue." B. "I will use the palmar surface of my hands to perform breast palpation." C. "I will lie down and put one hand behind my head to examine the breast on the opposite side of my body." D. "I will examine my breasts after bathing and drying thoroughly."

A. "I will use circular motions to feel the texture of my breast tissue." Rationale: The client should use small, circular motions to palpate the breast and underlying tissue. Therefore, the nurse should identify this statement as an indication that the client understands breast self-examination techniques.

A nurse is inspecting a client's axillae. Which of the following should the nurse identify as an expected finding? A. Skin is deeply pigmented B. Presence of plaques C. Fixation of tissue during arm movement D. Skin has a uniform consistency

D. Skin has a uniform consistency Rationale: The nurse should identify that the client's axillae should be smooth and intact.

A nurse is discussing breast cancer with a group of male clients. The nurse should include that which of the following findings is a potential indication of breast cancer? (Select all that apply.) A. Dilation of the hair follicles B. Bilateral tissue enlargement C. Nipple retraction D. A small bulging nodule lateral to one breast E. Palpable Montgomery glands

Rationale: Dilation of the hair follicles is correct. The nurse should include that dilation of the hair follicles of the breast, also known as peau d'orange, is a potential indication of possible breast cancer that should be reported to the provider. Nipple retraction is correct. The nurse should include that nipple retraction is a potential indication of breast cancer that should be reported to the provider. The client should also report the presence of nipple discharge. A small bulging nodule lateral to one breast is correct. The nurse should include that a small bulging nodule lateral to one breast is a potential indication of breast cancer that should be reported to the provider.

A nurse is teaching a client about performing a breast self-examination at home. In which order should the nurse instruct the client to perform the steps of breast self-examination?

Rationale: Look at the breasts in front of a mirror with hands placed on hips is the first step. The nurse should instruct the client to first look at their breasts in front of a mirror with their hands placed on their hips. This position contracts the muscles of the chest wall, which makes it easier to observe changes in breast tissue. Inspect the breasts for changes in shape, color, or contour is the second step. After positioning themselves in front of a mirror, the client should then look for changes in the shape, color, or contour of their breasts. Inspect the nipples for a rash or drainage is the third step. Next, the client should inspect their nipples for a rash or drainage. Lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers is the fourth step. Next, the client should lie down and prepare to palpate the breasts using the pads of the second, third, and fourth fingers. Palpate each breast from the outer edge, moving from top to bottom across the breast is the fifth step. Lastly, the client should palpate each breast from the outer edge, moving from top to bottom across the breast using light, medium, and firm palpation.

A nurse is caring for a male client who was recently diagnosed with gynecomastia. Which of the following should the nurse identify as a potential cause of this condition? A. Presence of the BRCA1 gene B. Medication adverse effects C. Decreased estrogen levels D. Decreased thyroid hormone levels

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

A nurse is performing a breast inspection during a client's routine physical examination. Which of the following findings should the nurse report to the provider? A. Areolas are oval-shaped B. Scaley skin at the border of one areola C. Small bumps visible on each areola D. Areolas have darker pigment than the surrounding skin

B. Scaley skin at the border of one areola Rationale: The nurse should identify that the presence of scaley skin on the breast is an unexpected finding. The nurse should report this finding to the provider for further evaluation.

A nurse is teaching a group of female clients about breast self-awareness. Which of the following instructions should the nurse include? A. Breasts are the least tender during the first 3 days of the menstrual cycle. B. Females can discontinue breast self-examination after menopause. C. Menstruating females should examine their breasts about 5 days after their menstrual cycle begins. D. Benign breast nodules are less prominent during the premenstrual phase.

C. Menstruating females should examine their breasts about 5 days after their menstrual cycle begins. Rationale: The nurse should instruct the client to perform breast self-examination 4 to 7 days after the onset of their menstrual cycle. This time is optimal because breasts are at their smallest and least congested. Before onset of menstruation, breasts tend to swell and are more nodular from increasing levels of estrogen.

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the client's breasts? A. Standing upright with their arms held straight out to their sides B. Bending over at the waist with hands reaching toward the toes C. Sitting straight up with arms relaxed and close to the body D. Lying supine with hands clasped together at the umbilicus

C. Sitting straight up with arms relaxed and close to the body Rationale: Prior to inspecting the client's breasts, the nurse should place the client in a seated position with their arms relaxed at their sides. The nurse should also drape the client's gown at waist-level to allow for visualization of the anterior chest.

A nurse is performing a breast inspection on a client. Which of the following findings should the nurse report to the provider? A. Striae B. Flat, brown nevi C. Visible capillaries beneath the skin surface bilaterally D. Dimpling

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

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health? Select all that apply A. Ask the client to describe the process for breast self-examination at the end of the teaching. B. Document instructions provided in the client's medical record. C. Provide the client with information about the human papilloma virus (HPV) vaccine. D. Review recommendations for mammography based on risk with the client. E. Begin the teaching by listing national guidelines for breast screening.

Rationale: Ask the client to describe the process for breast self-examination at the end of the teaching is correct. The nurse should ask the client to describe the process for breast self-examination at the end of the teaching to validate their understanding of the information. Document instructions provided in the client's medical record is correct. The nurse should document any education provided or reinforced with the client in the medical record as part of accurate documentation. Review recommendations for mammography based on risk with the client is correct. The nurse should review recommendations for breast screenings, such as mammography, with the client based on their risk factors.