Assessing Breast and Lymphatics: Thorax and Lungs

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

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

A 42-year-old 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?

"Be sure to have your breasts checked by a doctor and have a mammogram every year." It is acceptable for clients to choose not to do breast self-examination or to do it irregularly. The nurse needs to respect the client's choice. In addition, it would be important for the nurse to underscore the necessity of yearly mammograms and clinical breast examinations. Telling the client that she should do the examination undermines the client's right to choose. Telling the client that mammograms don't always detect problems and that the client won't have a choice after age 50 are threatening and demeaning.

The nurse is conducting the health interview of an adult client who has sought care because of a "wicked cough" leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?

"How long have you been experiencing your cough?" All of the listed questions are valid interview questions. However, gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections.

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?

"Please say the number "ninety-nine" for me." To palpate for fremitus, the nurse uses the ball or ulnar edge of one hand to assess for vibrations of air in the bronchial tubes transmitted to the chest wall. As the nurse moves a hand to each area, the client is asked to say "ninety-nine." None of the other listed actions will allow the nurse to assess for vibration in the chest wall.

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

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?

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

The nurse assess four male clients. In which client would the nurse expect to note gynecomastia during the assessment?

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

The nurse assess four male clients. In which client would the nurse expect to note gynecomastia during the assessment?

A 14-year-old boy who began puberty last year Gynecomastia may be seen in one breast in males during puberty for a temporary time. There are alternative causes of this phenomenon, but medications, workplace hazards, and cancer are not among them.

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

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

Air passing through constricted passageways Wheezes appear when air passes through constricted passages. Wheezes are not the result of diversion of air to the bronchi, increased turbulence, or air entering the pleural space.

During a prenatal class, a participant says that she was told that her breasts are not large enough to breast-feed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which variable?

Amount of glandular tissue The glandular tissue constitutes the functional part of the breast allowing for milk production. The amount of glandular tissue determines functional capacity of the breast, not the breast size, amount of fatty tissue, or subcutaneous fat layer.

The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths/min. How should the nurse respond to this assessment finding?

Ask the client if she has recently exerted herself Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral. Palpation is unlikely to ascertain the cause of the increased respiratory rate. Smoking is a possible cause, but activity is more likely.

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?

Ask the client to demonstrate BSE At the conclusion of the breast assessment, the nurse should ask the client to demonstrate how she performs BSE if she chooses to receive feedback on her technique and method. BSE should be performed regularly, but not as often as possible. It is not necessary to enlist the client in promoting BSE to her peers, although this may be appropriate. Return demonstration should precede repeated teaching.

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

What does the nurse use to formulate a nursing care plan?

Assessment data

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?

Asthma

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section comparing the right chest with the left chest

During the health interview, the nurse asks a client at what age she began menstruating. This question addresses a risk factor for what health problem?

Breast Cancer Early menses (before age 13) or delayed menopause (after age 52) increases the risk for breast cancer. Early menses is not linked to benign breast disease, Paget disease, or mastitis.

Screening measures for breast cancer include all of the following except:

Breast X Rays

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

COPD

The nurse is performing the technique shown. What is the nurse assessing? hands like a butterfly on back assessing breathing

Chest expansion

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

Chronic obstructive pulmonary disease (COPD)

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

Clear

A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding?

Decreasing intensity is normal at the base

It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?

Delirium

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

Diaphrgam

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?

Evaluate changes in respiratory pattern and rate

A personal history of breast cancer will decrease the risk of cancer reoccurring in other areas of the body

False

Due to a decreased level of progesterone, the older client will notice a decrease in the size of the firmness of the breasts as she ages

False Decreased level of estrogen

Dimpling or retraction of the breasts is typically caused by a fibroadenoma.

False caused by a malignant tumor

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

Friction rub

The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What would the nurse expect to hear when auscultating the lungs of this client?

Friction rub The pleural space is one of the physiologic third spaces for body fluid storage. Severe dehydration will reduce the volume of pleural fluid, resulting in the increased transmission of lung sounds and a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngospasm, such as croup.

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings? You Selected:

Funnel Chest (pectus excavatum)

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

A client has large, pendulous breasts. What would be most appropriate to ensure better access while examining the client's breasts for retraction and dimpling?

Have the client sit and then lean forward Asking the client to lean forward from the waist is a good position to use for women with large pendulous breasts. It allows for better visualization than the other listed positions.

During the health interview, a client tells the nurse that he "can't breathe all that well" at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for what health problem?

Heart Failure

During a health-screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?

History of tobacco use Pollution and occupational toxins are risk factors for lung cancer, but cigarette smoking is the primary risk factor. Infections do not usually precede lung cancer.

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. What information would the nurse include?

Increase in fatty tissue With aging, the older adult may notice a decrease in the size and firmness of the breasts due to a decrease in estrogen levels. Glandular tissue decreases, whereas fatty tissue increases. The older adult client may have smaller, flatter nipples, and breasts may feel more granular.

The techniques used for assessing the breast include: (Select all that apply) Inspection Auscultation Palpation Percussion

Inspection Palpation

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

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? Move from anterior to posterior on the same side Listen at each site for at least 1 complete respiratory cycle

Listen at each site for at least 1 complete respiratory cycle

The steps that are recommended for performing a Breast self-exam include: (Select all that apply) Looking at your breasts standing in front of a mirror Raise your arms up and determine if you see the same changes occur Look for any fluid coming out of the nipples Lying down, palpate the breast with three fingers going in a circular motion and up/down motion to feel for any lumps Palpate the breasts while in the shower using same hand motions as identified above Look at your breasts standing in front of a mirror Raise your arms up and determine if you see the same changes occur Look for any fluid coming out of the nipples Lying down, palpate the breast with 3 fingers going in a circular motion and up/down motion to feel for any lumps Palpate the breasts while in the shower using same hand motions as identified above

Look at your breasts standing in front of a mirror Raise your arms up and determine if you see the same changes occur Look for any fluid coming out of the nipples Lying down, palpate the breast with 3 fingers going in a circular motion and up/down motion to feel for any lumps Palpate the breasts while in the shower using same hand motions as identified above

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?

Loss of involuntary respiratory control

The thoracic cavity contains which of the following organs? Select all that apply.

Lungs Heart Most of the esophagus

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms? You Selected:

Lymphadenopathy

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage

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

One breast larger than the other

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. Breast fullness and pain B. Elastic, tender, mobile lumps C. Orange peel-like appearance D. Irregular, firm lumps E. Redness and warmth with smooth texture F. Dimpling and nipple retraction

Orange peel like appearance Irregular, firm lumps Dimpling and nipple retraction Indications of possible breast cancer include - - Irregular, firm, hard, not defined masses that may be fixed or mobile - Dimpling and nipple retraction and an orange peel-like appearance. Elastic tender mobile lumps = benign breast disease. Redness and warmth with a smooth texture = inflammation or infection. Breast fullness and pain can occur just before menses.

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

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

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?

Patient C

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

A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum?

Pink and Frothy Pink sputum is associated with pulmonary edema. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

The caretaker of an elderly person tells the nurse that she is worried that the client will choke because of swallowing problems secondary to a recent cerebrovascular accident (CVA). What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client? Keep the client upright for 30 minutes after eating Prepare foods that are pudding consistency or semisolid

Prepare foods that are pudding consistency or semisolid

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

Progesterone

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

Raise arms over the head

The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find?

Red and scaling on the areola Red, scaly crusty areas are indicative of Paget disease. Orange-peel skin and nipple retraction are associated with cancer. A dark pink areola is a normal finding.

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all fields

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration.

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?

Slight kyphosis Kyphosis (an increased curve of the thoracic spine) is common in older clients. Inaudible lung sounds, wheezing, and asymmetrical expansion are considered pathologic findings in clients of all ages.

The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?

Slightly above the clavicle The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib and posteriorly, the base lies at about the tenth rib.

When assessing whispered pectoriloquy, what would the nurse instruct the client to do?

Softly repeat the words "one-two-three." Softly whispering "one-two-three" while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say "ninety-nine" is used to test bronchophony. Saying the letter "e" is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

Suprasternal notch

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

TB

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

Teaching strategies to reduce complications of existing diagnoses

During palpation of the breasts in a client who is not pregnant, the nurse will expect to identify the following: (Select all that apply) Tenderness Elasticity and texture Milky discharge (for a patient who is not pregnant)

Tenderness and temperature Elasticity and texture

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes. The right lung is made up of three lobes, whereas the left lung contains only two lobes. The sizes of the lungs are not identical but do not differ by one third. The lower lobes of both lungs are primarily located toward the posterior surface of the chest wall.

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

Thoracic cavity enlarges

A pigskin-like or orange-peel appearance results from edema, which is seen in metastatic breast disease.

True

Fremitus includes palpation for vibrations of air that are transmitted to the chest wall T/F

True

Gynecomastia is the term used to describe an enlargement or swelling of breast tissue in males.

True

Scoliosis involves abnormal lateral deviation of the spine making the spine appear to be curved. T/F

True

The supraclavicular, midaxillary, and pectoral lymph nodes assist in draining impurities from the breasts.

True

Which terms are used to identify the lobes of the right lung? Select all that apply.

Upper Middle Lower

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

Upper outer quadrant

The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment?

Use the flat pads of three fingers. When palpating the breasts, the nurse should use the flat pads of three fingers to palpate. The fingertips, palms, and pinching are inappropriate techniques.

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

Vertebral line The reference lines for the posterior thorax include the vertebral line and right and left scapular lines. The midaxillary line is a reference line for the lateral aspect of the thorax. The right midclavicular line and sternal line are reference lines for the anterior thorax.

The nurse auscultates the base of the lungs to assess for what reason?

it is where fluid occurs with pulmonary edema

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

manubrium

What is considered a modifiable risk factor for breast cancer?

obesity

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

pneumonia

A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is

the degree to which dyspnea affects daily function.