The nurse is assessing a client's breasts. When assessing the area of the breast most vulnerable to breast cancer, where should the nurse to assess?
B) Upper outer quadrant
During a prenatal class, a participant says that she was told that her breasts are not large enough to breastfeed. When responding to this client, the nurse should understand that the functional capacity of the breast is primarily determined by which of the following variables?
D) Amount of glandular tissue
The nurse has asked a female client if she has noticed any lumps or swelling in her breasts. After the client responds “yes,” which question should the nurse ask next?
C) “Does the lump change over the course of your menstrual cycle?”
When taking a health history for a female client, which factor should the nurse identify as placing the client at increased risk for breast cancer?
A) The client smokes six to eight cigarettes per day
B) The client had her first child at age 38
C) The client breast-fed her child for a full year
D) The client has a low body mass index
B) The client had her first child at age 38
Which of the following factors should a nurse include when discussing risk factors about breast cancer for a group of women?
A) Early menarche
While assessing a woman's breasts, the nurse notes a pronounced and asymmetric pattern of veins on the client's breasts. Follow-up care is ordered because the nurse
should suspect which of the following?
B) Malignancy
A 42-year-old female 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?
D) “Be sure to have your breasts checked by a doctor and have a mammogram every
year.”
An 18-year-old woman complains because one breast is larger than the other. What additional interview data would suggest a need for referral?
A) The client states that this represents a sudden change in her breast size.
The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. Which of the following would the nurse expect to find?
D) Red and scaling on the areola
A woman reports a sudden onset of spontaneous nipple discharge. Which of the following would be the nurse's most appropriate action?
C) Refer the client for cytologic study of the discharge.
The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Which
position would be most appropriate?
A) Sitting
A client has large, pendulous breasts. Which of the following would be most appropriate
to ensure better access while examining the client's breasts for retraction and dimpling?
D) Have the client sit and then lean forward
The nurse is preparing to palpate the breasts of a female client. Which technique should the nurse utilize during this aspect of assessment?
A) Use the flat pads of three fingers.
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?
B) “You seem to be anxious. Can you tell me what you are thinking?”
A nurse has completed the assessment of a client's breasts. The nurse should suspect that the client has fibroadenomas based on which findings?
A) Lobular, ovoid, or round lesions
B) Irregular, firm cysts
C) Round, defined mobile cysts
D) Nondefined, mobile cysts
Lobular, ovoid, or round lesions
After teaching a group of young women about breast self-examination, the nurse determines that the teaching was successful when the women state that they will palpate
their breasts using which pattern?
B) An up-and-down pattern
When palpating a female client's axillae, which of the following actions is most
appropriate?
A) Have the client hold the arm of the side being examined slightly away from the
body.
B) Tell the client to raise her arm on the side being examined up over her head.
C) Hold the client's elbow of the side being examined with one hand.
D) Have the client lean forward from the waist with arms outstretched.
C) Hold the client's elbow of the side being examined with one hand.
When palpating a female client's axillae, which finding would the nurse document as normal?
D) Nodes are discrete.
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. Which of the
following would the nurse include?
A) Increase in fatty tissue
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.
B) Irregular, firm lumps
C) Dimpling and nipple retraction
D) Orange peel-like appearance
A client has presented for care to the clinic, stating, “I'm pretty sure that I feel a new lump in my breast.” After confirming the presence of a lump, what action should the nurse take?
D) Arrange for a prompt referral to her primary care provider.
A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?
A) “How would you describe your pain? Is it sharp? Is it an ache?”
During the health interview, the nurse asks a middle-aged client at what age she began menstruating. This question addresses a risk factor for what health problem?
C) Breast cancer
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?
C) Ask the client to demonstrate BSE.
The nurse is beginning the inspection of a young adult client's breasts. The client states,“My left breast has always been a bit bigger than the right.” How should the nurse best respond to the client's statement?
A) “Many women have this, and it's rarely a sign of a health problem.”
B) “That's very normal, and it usually resolves over time as you get older.”
C) “If you lose some weight, the size disparity will likely decrease.”
D) “I'll make sure to refer to the doctor to get this assessed further.”
The nurse is examining a client's breasts and notes the presence of pronounced dimpling. How should the nurse best respond to this assessment finding?
B) Promptly refer the client for further medical assessment.
The nurse is assessing an adult client's areolas and nipples. What assessment finding would most clearly warrant referral?
B) The patient's nipple has recently become inverted.
The nurse is palpating the axillary lymph nodes of a client who has been experiencing recent malaise. The nurse should consider a lymph node to be enlarged if its diameter exceeds what size?
B) 1 cm
In which of the following male clients would gynecomastia be considered to be an expected assessment finding?
C) A 14-year-old boy who began puberty last year
Assessment of a client's breasts reveals tenderness on palpation and diffuse redness.
What collaborative problem is most clearly suggested by these data?
