breast and regional lymphatics
The nurse is assessing a 13-year-old male patient who is concerned about the sudden enlargement of his breasts. Which responses by the nurse are appropriate?
"It is a normal but temporary occurrence at your age." "The enlargement will go away and may reappear in old age." "The enlargement is the result of a normal growth of breast tissue."
The nurse is teaching an adolescent who was diagnosed with fibroadenoma in the left breast. Which statement by the nurse would be appropriate?
"It is benign and may resolve spontaneously."
The nurse is caring for a lactating patient who has a breast abscess on the right breast. Which instructions should the nurse provide to this patient?
"Nurse only on the unaffected side."
The nurse is screening a patient for retraction of the breasts. How does the nurse instruct the patient during this screening?
"Push the palms together." "Put both the hands on the hips." "Lift both the arms slowly over the head."
During a physical assessment, a teenager tells the nurse, "My left breast is smaller than the right one and it makes me feel self-conscious." How should the nurse respond?
"You shouldn't worry; this is a normal condition."
Which intervention does the nurse perform while examining the axillae of a patient?
Move the arm through the range of motion.
Which information should the nurse provide to a lactating patient with a plugged duct?
...
Which patient is likely to have mammary duct ectasia?
A perimenopausal woman who has lactated
The nurse is performing a clinical breast examination (CBE) on a patient. Which assessment finding should the nurse refer for further investigation?
A recent increase in size in one of the breasts
The nurse is caring for a lactating patient. Which assessment finding indicates the presence of a plugged duct?
A section of the breast appears red and tender.
What are the appropriate nursing interventions while examining the breast of a male patient?
Inspect the chest wall and the skin surface for lumps. Combine with the examination of the anterior thorax. Palpate the nipple area and axillary lymph nodes.
What is a normal finding in the breasts of a prepubertal child?
The areola has darker pigmentation with flat nipples.
What is the proper method to examine large pendulous breasts?
Asking the patient to lean forward while the nurse supports the forearms
What is the marked change in the breast seen in a patient who has reached menopause?
Atrophy of the glandular tissue
What does the nurse teach the patient about breastfeeding?
Breast milk is whitish and contains proteins, lactose, and fats. The breasts produce colostrum for the first few days after delivery. The antibodies in colostrum protect the newborn against infection.
What nipple discharge does the nurse expect to find in a patient with early lesions in Paget disease?
Clear, yellow discharge
While teaching a group of patients about breast cancer, which factors does the nurse relate to an increased risk of breast cancer?
Consumption of alcohol Postmenopausal weight gain Use of canned fish and mayonnaise
What is a sign of skin tether in the breast?
The areola seems distorted and has a dimple
The nurse is assessing a patient who reports finding a lump in the left breast. Which intervention by the nurse is most appropriate?
Examine the features of the right breast followed by the left breast.
Which factors are responsible for a 1.1 to 2.0 relative risk of breast cancer?
Exposure to diethylstilbestrol (DES) Absence of full-term pregnancies Menopause after 55 years of age
What is the cause of gynecomastia in a patient with Cushing syndrome?
Inability to metabolize estrogens
The nurse is assessing a patient with large, pendulous breasts for retraction. Which is the best intervention by the nurse?
Instruct the patient to lean forward as the nurse supports the arms.
What is a characteristic of fibroadenoma?
It is freely moveable and feels firm and elastic.
The nurse is caring for a patient with cracked nipples due to breastfeeding. What instructions should the nurse provide to the patient?
Keep the area clean, dry, and exposed to the air.
The nurse is caring for a patient with a plugged duct. How much time does it take to resolve this condition if properly treated?
Less than a day
What is the term used by the nurse to describe pain in the breast?
Mastalgia
The nurse is teaching nursing students about fibrocystic disease. Which signs and symptoms should the nurse include in the teaching plan?
Mastalgia Mastalgia Swelling and tenderness
The nurse is caring for a patient in the second month of lactation. The patient has an inflammatory mass forming outward from the areola and flu-like symptoms. What is the diagnosis for this patient?
Mastitis
What does the nurse teach a premenopausal, nonpregnant patient about the best time to perform breast self-examination (BSE)?
On days 4 to 7 of the menstrual cycle
The breast has four groups of axillary nodes. Where is the central axillary node located?
Over the ribs and serratus anterior muscle
The nurse is examining the breast of a patient. The nurse observes a small crust on the nipple apex that has spread to the areola. Which condition does the nurse suspect in the patient?
Paget's disease
Which assessment finding does the nurse associate with fibrocystic disease?
Pain increase before menses
The nurse notices edema on the breast skin of a patient that has a "pigskin" look. Which condition does the nurse suspect from this observation?
Peau d'orange
What assessment finding does the nurse identify with gynecomastia in an older male patient?
Presence of a bilateral, tender, firm mass
The nurse is assessing a patient who reports purulent nipple discharge. What is the likely cause of this condition?
Stagnation of cellular debris in the ducts
What is the best intervention by the nurse while assessing a patient over the age of 50?
Suggest use of talcum powder for breast self-examination.
The nurse is assessing a patient's breasts. Which finding does the nurse identify as abnormal?
The presence of localized redness with heat
Which assessment finding does the nurse associate with a diagnosis of peau d'orange?
The skin is thickened, and the hair follicles exaggerated.
Which part of the breast is called the tail of Spence?
The superior lateral corner
Which findings are normal in the breast examination of a lactating 20-year-old patient?
There is a slight enlargement and tenderness. The lobes feel prominent, with distinct margins. There is a transverse tissue in the lower quadrant.
The nurse is assessing a patient after a mastectomy on the right side. Which assessment finding is a cause for concern?
There is redness and warmth around the scar.
The nurse is doing a breast assessment of a pregnant patient. On palpation, the nurse finds that the breasts feel nodular. The patient does not complain of any pain. What does the nurse deduce from these findings?
This is a normal finding.
The nurse takes special care while checking a patient's tail of Spence. What is the reason for this intervention?
To detect breast cancer
Before a breast examination, the nurse asks the patient to lie down and raise her arms. What is the rationale behind this instruction?
To flatten the breast tissue
