Chapter 16 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 16

Question 1

Type: MCMA

The nurse is conducting a breast health workshop for a group of women. Which of the following would the nurse include in this workshop when outlining risk factors for breast cancer?

Standard Text: Select all that apply.

1. Caucasian race

2. Positive family history

3. Low socioeconomic status

4. Hormone replacement therapy

5. Female age 35 to 40

Correct Answer: 1,2,3,4

Rationale 1: Caucasian race. Caucasian females, especially over the age of 40 have a higher risk of developing breast cancer than any other race or ethnic group.

Rationale 2: Positive family history. A positive family history of breast cancer places an individual at a higher risk of developing breast cancer. The individual is at an even greater risk if the family member developed breast cancer prior to menopause.

Rationale 3: Low socioeconomic status. Lower socioeconomic status places an individual at risk for breast cancer for a number of reasons, including lack of education on preventative measures and diagnostic recommendations; fear that breast cancer is not treatable and has a high mortality rate, thus they avoid diagnosis; and the mother of the family in lower socioeconomic groups often places her familys health care needs above hers.

Rationale 4: Hormone replacement therapy. Hormone replacement therapy is linked to higher incidence of breast cancer.

Rationale 5: Female age 35 to 40. Females between the ages of 35 to 40 have not been found to have a high incidence of breast cancer.

Global Rationale: Caucasian females over the age of 40, positive family history, low socioeconomic status, and taking hormone replacement therapy are risk factors for breast cancer. Females from 35 to 40 years of age are not at a high risk for developing breast cancer.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts.

Question 2

Type: MCSA

The nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infants nipple. The nurse knows this is a:

1. congenital anomaly.

2. highly irregular finding.

3. reason to call in a specialist.

4. common finding in newborns.

Correct Answer: 4

Rationale 1: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides as the infants body eliminates maternal hormones. This is not considered a congenital anomaly.

Rationale 2: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides as the infants body eliminates maternal hormones; therefore, this is not considered an irregular finding.

Rationale 3: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides as the infants body eliminates maternal hormones; therefore, there would be no reason to contact a specialist.

Rationale 4: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy, and some infants may produce a thin discharge called witchs milk, which subsides as the infants body eliminates maternal hormones; therefore, this assessment finding is common in newborns.

Global Rationale: The breast tissue of newborns is sometimes swollen because of hyperestrogenism of pregnancy. Some infants may produce a thin discharge called witchs milk, which subsides as the infants body eliminates maternal hormones. This is neither irregular nor hereditary, and there is no reason to call on a specialist.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 3

Type: MCSA

A female client is hospitalized with injury and tissue destruction of the left pectoralis major and serratus anterior muscles due to a motor vehicle accident. The nurse would include which of the following information during the discharge teaching?

1. Prosthestic devices

2. Support bras

3. Plastic surgery

4. Physical therapy

Correct Answer: 2

Rationale 1: A prosthetic device is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary.

Rationale 2: Discharge teaching regarding the need for the client to wear a support bra would be indicated in this scenario since injury has occurred to the left pectoralis major and serratus anterior muscles, as these comprise the suspensory ligaments of the breasts.

Rationale 3: Plastic surgery is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary.

Rationale 4: Physical therapy is not indicated as treatment in this scenario, so discharge teaching for such devices is not necessary.

Global Rationale: The overall contour of the breasts is determined by the suspensory ligaments, which provide support, and the major muscles of support are the pectoralis major and serratus anterior muscles. The major function of the muscles of the chest wall is to support breast and lymphatic tissue. Undergarments, which provide needed support after discharge, are an important part of the clients recoveryfor emotional as well as physical health. Although prostheses, plastic surgery, and physical therapy may all be part of the comprehensive care plan, supporting the breast and lymph tissue until such time as muscle strength is restored or reconstructed would be an important nursing intervention.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae.

Question 4

Type: MCSA

The nurse is using inspection to assess the breasts of a female client. Which of the following findings might the nurse obtain using this assessment technique?

1. Symmetry

2. Hard nodules

3. Tenderness

4. Skin consistency

Correct Answer: 1

Rationale 1: Symmetry of the breasts indicates that both breasts are nearly the same size and shape. This assessment is performed by the technique of inspection.

Rationale 2: Hard nodules in the breast tissue cannot be assessed by inspection. Palpation would be necessary for this type of assessment.

Rationale 3: Tenderness cannot be assessed by inspection. Palpation would be necessary for this type of assessment.

Rationale 4: Skin thickening cannot be assessed by inspection. Palpation would be necessary for this type of assessment.

Global Rationale: Symmetry is the only finding that the nurse would assess using the technique of inspection when examining the breasts. The remaining findings would all be obtained using the technique of palpation.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae.

Question 5

Type: MCMA

The nurse is teaching an older adult client about breast self-examination (BSE). Which of the following should the nurse provide during this instruction?

Standard Text: Select all that apply.

1. Additional lighting

2. Increased time

3. Opportunity for questions

4. Large-print handouts

5. A quiz at the end of the instruction

Correct Answer: 1,2,3,4

Rationale 1: Additional lighting. Additional lighting may be necessary when teaching the older adult client about BSE due to failing eyesight in some of these clients.

Rationale 2: Increased time. More time may be required for the focused interview of the older client who may have a more difficult time talking about something as private as the breasts.

Rationale 3: Opportunity for questions. Allowing an ample amount of opportunity for questions is necessary for some older adults who may take longer to process new information.

Rationale 4: Large-print handouts. Large-print handouts may be necessary when teaching the older adult client about BSE due to failing eyesight in some of these clients.

Rationale 5: A quiz at the end of the instruction. A quiz at the end of the instruction is not indicated as this may cause the client to feel undue stress.

Global Rationale: More time may be required for the focused interview of the older client who may have a more difficult time talking about something as private as the breasts. Limited range of motion and failing eyesight are some of the physical changes that accompany the aging process. Providing additional lighting, moving at a slower pace, and using handouts or pamphlets with large print may be helpful. A quiz would not be indicated as this may cause the client to experience undue stress.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and cultural variation that guide assessment.

Question 6

Type: MCSA

The nurse is asking a client questions regarding lifestyle patterns. Which of the following statements by the client would alert the nurse to possible risk for breast cancer?

1. I work in a chemical factory.

2. I drink two glasses of wine each night.

3. I have smoked two packs of cigarettes daily for four years.

4. I occasionally have unprotected sexual contact with unknown partners.

Correct Answer: 2

Rationale 1: Exposure to chemicals by working in a chemical factory would place the client at risk for developing lung-related cancers or other body system cancers or disease.

Rationale 2: Research indicates that alcohol intake in excess of nine drinks per week may increase a womans risk of developing breast cancer. Two glasses of wine each night totals 14 drinks per week.

Rationale 3: Smoking two packs of cigarettes daily for four years would place the client at risk for developing lung-related cancers or disease.

Rationale 4: Occasional unprotected sexual contact with unknown partners increases risk for STDs, HIV, as well as cervical cancer.

Global Rationale: Research indicates that a high-fat diet may increase a womans risk of developing breast cancer as well as alcohol intake in excess of nine drinks per week. Exposure to chemicals and cigarette smoke would place the client at risk for developing lung-related cancers or disease, and unprotected sexual contact increases risk for STDs, HIV, as well as cervical cancer.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.2: Develop questions to be used when completing the focused interview.

Question 7

Type: MCSA

The nurse is teaching selfbreast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the nurse why this is necessary. The nurse would respond with which of the following?

1. It allows any masses to bulge forward to be seen.

2. This is the only position to detect Pagets disease.

3. This is the best position to look for skin dimpling.

4. It is the only way to look for nipple retraction.

Correct Answer: 3

Rationale 1: Masses are rarely visible with inspection so stating that this position would allow for any masses to bulge forward to be seen is an inaccurate statement.

Rationale 2: Pagets disease is a rare type of breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction, does not have to be visualized with the arms over the head.

Rationale 3: This statement is accurate since recent dimpling of the skin over a mass is often a visible sign of breast cancer, and it is accentuated with the clients arms over the head.

Rationale 4: Nipple retraction is a possible sign of breast cancer, but it does not require the arms over the head for visualization.

Global Rationale: Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the clients arms over the head. Pagets disease is a rare type of breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction, does not have to be visualized with the arms over the head. Masses are rarely visible with inspection.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae

Question 8

Type: MCSA

The nurse is assessing a client and confirms the presence of galactorrhea. The nurse understands that this finding is:

1. suggestive of endocrine disorders.

2. may indicate a malignancy.

3. probably an infection.

4. usually indicative of lactation.

Correct Answer: 1

Rationale 1: Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressant and antihypertensive medications.

Rationale 2: Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma, or it may indicate a malignancy.

Rationale 3: Infections of the breast often cause enlargement and tenderness of the axillary lymph nodes.

Rationale 4: Normal lactation is associated with childbearing and is not called galactorrhea.

Global Rationale: Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressants and antihypertensives. Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma, or cancer. Infections of the breast cause enlargement and tenderness of the axillary lymph nodes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae

Question 9

Type: MCMA

The nurse is examining a client with a history of benign breast disease (sometimes referred to as fibrocystic breast disease). The nurse would expect which of the following findings during this assessment?

Standard Text: Select all that apply.

1. Straw-colored discharge from the nipples

2. Freely movable masses

3. Hard, fixed nodules

4. Thickened breast tissue

5. Masses with well defined boundaries

Correct Answer: 1,2,4,5

Rationale 1: Straw-colored discharge from the nipples. Straw-colored discharge from the nipples is common with benign breast disease. Discharge from the nipples may be clear, straw-colored, milky, or green.

Rationale 2: Freely movable masses. Masses with benign breast disease are generally freely movable.

Rationale 3: Hard, fixed nodules. Hard, fixed nodules are more commonly associated with cancer of the breast.

Rationale 4: Thickened breast tissue. The symptoms of benign breast disease are a result of fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst formation.

Rationale 5: Masses with well defined boundaries. The masses of benign breast disease are typically well demarcated (having defined boundaries).

Global Rationale: Upon palpation of fibrocystic breasts, the masses feel soft, well demarcated and freely movable. Discharge from the nipples may be clear, straw-colored, milky, or green. These symptoms are a result of fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst formation. Hard, fixed nodules are suggestive of cancer of lymphoma.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 10

Type: MCSA

The nurse is teaching a client with benign breast disease about symptom relief. Which of the following topics would the nurse include in this session?

1. Avoiding all fat in the diet

2. Wearing a firm bra

3. Limiting salt intake

4. Drinking tea instead of coffee

Correct Answer: 3

Rationale 1: Avoiding all fat in the diet is not advisable for any client; limiting the amount of saturated fats may help alleviate pain associated with benign breast disease.

Rationale 2: Wearing a firm bra has not been identified as treatment method for pain associated with benign breast disease.

Rationale 3: Limiting salt intake has been found to help alleviate pain associated with benign breast disease.

Rationale 4: Limiting caffeine is advisable to help alleviate the pain associated with benign breast disease; however, drinking tea instead of coffee would not help since both contain caffeine.

Global Rationale: Symptom management includes such things as pharmacological hormones, diuretics, limiting caffeine, wearing a supportive bra, and decreasing salt intake may help relieve symptoms of breast pain and tenderness, especially in the premenstrual period.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts.

Question 11

Type: MCSA

The nurse is teaching a group of high school males about selfbreast examination. The nurse knows the teaching has been effective when one of the males makes which of the following comments regarding breast cancer in males?

1. I need to be concerned only if I have pain in my chest.

2. I know that I need to do monthly selfbreast exams.

3. Ill be able to know about problems if I see changes in my chest.

4. Breast cancer is not something I have to worry about.

Correct Answer: 2

Rationale 1: I need to be concerned only if I have pain in my chest is an inaccurate statement since pain may or may not be present with male breast cancer.

Rationale 2: I know that I need to do monthly selfbreast exams is a correct statement as breast cancer in the male is usually identified as a hard nodule fixed to the nipple and underlying tissue and is best detected by palpation.

Rationale 3: Ill be able to know about problems if I see changes in my chest is inaccurate since the most common area for nodules to occur in the male breast is near the nipple, other signs like dimpling, asymmetry, peau dorange, and areolar color changes may not be as noticeable.

Rationale 4: Breast cancer is not something I have to worry about is an inaccurate statement since teaching the male client to do monthly breast self-examinations is as important as for the female client for early detection of breast cancer.

Global Rationale: Teaching the male client to do monthly breast self-examinations is as important as it is for the female client. Breast cancer in the male is usually identified as a hard nodule fixed to the nipple and underlying tissue and is best detected by palpation. Normally, the male breast feels like a thin disc of tissue under a flat nipple and areola. Pain may or may not be present. Since the most common area for nodules to occur in the male breast is near the nipple, other signs like dimpling, asymmetry, peau dorange, and areolar color changes may not be as noticeable.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae.

Question 12

Type: MCSA

A pregnant client expresses concern about performing breast self-examination during pregnancy since her breasts are tender. Which of the following would be the best response by the nurse in this situation?

1. All you need to do is just concentrate on having a healthy baby for now.

2. You can wait until your breasts are no longer tender, and then resume your self-exams.

3. Its very important for you to be familiar with the changes in your breasts.

4. Breast cancer during pregnancy is rare, so dont worry about it.

Correct Answer: 3

Rationale 1: All you need to do is just concentrate on having a healthy baby for now is inappropriate since it leads the client to believe that it is not possible to have breast cancer during pregnancy. Selfbreast examination should be implemented throughout the pregnancy and during lactation.

Rationale 2: You can wait until your breasts are no longer tender, and then resume your self-exams is an incorrect statement since breast tenderness may continue throughout the pregnancy and lactation period. Selfbreast examination should be implemented throughout the pregnancy and during lactation.

Rationale 3: Its very important for you to be familiar with the changes in your breasts is the best response by the nurse since, although rare, breast cancer can occur during pregnancy and lactation; therefore, selfbreast examination should be implemented throughout the pregnancy and during lactation.

Rationale 4: While breast cancer during pregnancy is rare, the statement: Breast cancer during pregnancy is rare, so dont worry about it is inappropriate since breast cancer can occur during pregnancy and lactation. Selfbreast examination should be implemented throughout the pregnancy and during lactation.

Global Rationale: During pregnancy, breast self-examination needs to be done and the procedure is the same, even though the breast tissue will be firmer, larger, and possibly more tender. Breast cancer needs to be identified as soon as possible and is treated on an individual basis. It may not be common for breast cancer to occur during pregnancy, but monitoring for it does need to continue. Therefore, selfbreast examination must be implemented throughout the pregnancy and during lactation.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae

Question 13

Type: MCSA

The nurse is interviewing a 37-year-old client for breast cancer risks. The nurse understands that the client knows the risks associated with breast cancer when which of the following comments is made?

1. I know my risk for breast cancer increases with age.

2. A mammogram every three years is my goal.

3. I will see my healthcare provider every two years for a breast examination.

4. My family history is negative so I do not need to worry.

Correct Answer: 1

Rationale 1: I know my risk for breast cancer increases with age is the correct statement since breast cancer risks increase significantly after the age of 35 to 40.

Rationale 2: A mammogram every three years is my goal is not an accurate response. Mammography screening is dependent on several factors. Biennial screening is suggested between the ages of 50 and 74 years. Beginning biennial mammography before the age of 50 is based on cancer risk, and values regarding the benefit and harm associated with mammography.

Rationale 3: I will see my healthcare provider every two years for a breast examination is not an accurate response. Annual breast examination by a healthcare provider every 3 years for women from age 20 to 40 years, and annually thereafter, is suggested.

Rationale 4: My family history is negative so I do not need to worry is not an accurate response. The client should be aware of current screening guidelines regardless of family history.

Global Rationale: The risk of breast cancer increases with aging, especially after 3540 years of age. The most current American Cancer Society guidelines for breast cancer screening include: Mammography biennial screening between the ages of 50 and 74 years; beginning biennial mammography before the age of 50 should be an individual decision based on cancer risk, and values regarding benefit and harm associated with mammography; annual breast examination by a healthcare provider every 3 years for women from age 20 to 40 years, and annually thereafter; selfbreast examination is an option for women to consider beginning at the age of 20 All clients, regardless of family history, should be aware of screening guidelines.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts

Question 14

Type: MCMA

The nurse is compiling statistics for a breast cancer awareness presentation for a group of women. The nurse would correctly use which of the following facts about breast cancer?

Standard Text: Select all that apply.

1. Breast cancer is one of the most common cancers in females.

2. Rates are on the decline.

3. Associated mortality has declined.

4. Diagnostics have improved.

5. 25% of females in Western countries are genetically predisposed.

Correct Answer: 1,3,4

Rationale 1: Breast cancer is one of the most common cancers in females. Breast cancer, along with skin cancer, is the most common cancers in females.

Rationale 2: Rates are on the decline. Breast cancer rates are increasing.

Rationale 3: Associated mortality has declined. Rates of death from breast cancer have declined to approximately 1 in 35 women diagnosed with the disease.

Rationale 4: Diagnostics have improved. Diagnostics, such as mammography and breast ultrasound, have significantly improved.

Rationale 5: 25% of females in Western countries are genetically predisposed. 10%, rather than 25%, of females in Western countries are genetically predisposed to breast cancer.

Global Rationale: All of the statements are true with the exception of breast cancer rates, which are actually on the increase, not the decline, and 10 % of females in Western countries, rather than 25%, are genetically predisposed to breast cancer.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.2: Develop questions to be used when completing the focused interview.

Question 15

Type: MCSA

The nurse is performing a breast examination and is palpating into the tail of Spence. The nurse understands that this is necessary for which of the following reasons?

1. It does not contain any lymph nodes.

2. It can show the difference between fibrocystic disease and fibroadenomas.

3. Breast cancer occurs more frequently in this area.

4. Peau dorange may occur in this area of the breast.

Correct Answer: 3

Rationale 1: The area of the tail of Spence is in the upper outer quadrant of the breast into the axillary region, which does contain lymph nodes; therefore, this statement is not accurate.

Rationale 2: It would be difficult to detect the difference between fibrocystic disease, breast cancer, and fibroadenomas by palpation alonecorrelating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses.

Rationale 3: Breast cancer does occur more frequently in this area. The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence.

Rationale 4: Peau dorange and Pagets disease are changes in the breast skin and nipple area associated with forms of cancer; therefore, palpation in the tail of Spence area would not be a detection method for these abnormalities.

Global Rationale: The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence. Masses in the tail must be distinguished from enlarged lymph nodes. It would be difficult to detect the difference between fibrocystic disease, breast cancer, and fibroadenomas by palpation alonecorrelating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses. Peau dorange and Pagets disease are changes in the breast skin and nipple area associated with forms of cancer.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.4: Describe techniques for assessment of the breasts and axillae

Question 16

Type: MCSA

A menopausal woman comes to the clinic with complaints of thin, watery nipple discharge with blood present. The nurse would suspect which of the following disorders in this client?

1. Mammary duct ectasia

2. Fibrocystic disease

3. Breast malignancy

4. Intraductal papillomas

Correct Answer: 4

Rationale 1: Discharge associated with mammary duct ectasia is thick and sticky, rather than thin and watery, as a result of inflammation of the lactiferous ducts.

Rationale 2: Fibrocystic disease is first seen when women are in their twenties, and discharge is typically straw-colored, clear, milky, or green.

Rationale 3: Malignancy that affects the nipple must be correlated with other physical findings, mammogram, and biopsy. In addition, discharge is not typically thin and watery with breast malignancy.

Rationale 4: Intraductal papillomas, which are small growths of epithelial cells that extend into the lumen of the lactiferous ducts, are the primary cause of thin, watery nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women.

Global Rationale: Intraductal papillomas are the primary cause of nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women. Fibrocystic disease is first seen when women are in their twenties, and discharge may be straw-colored, clear, milky, or green. Discharge associated with mammary duct ectasia is thick and sticky. Malignancy that affects the nipple must be correlated with other physical findings, mammogram, and biopsy.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 17

Type: MCSA

The nurse is educating a prenatal class about lactation when one of the clients asks how milk is produced. The nurse would correctly identify which of the following structures as responsible for milk production?

1. Montgomerys glands

2. Areola

3. Acini cells

4. Mammary ridge

Correct Answer: 3

Rationale 1: Montgomerys glands are sebaceous glands; therefore, no milk production occurs from these glands.

Rationale 2: The areola circular wrinkled pigmented skin surrounding the nipple and is not responsible for milk production.

Rationale 3: Each lobe in the breast contains approximately 20 to 40 lobules that contain the acini cells, which produce milk.

Rationale 4: The mammary ridge is comprised of supernumerary nipples or breast tissue and extends from each axilla to the groin. No milk production occurs from this area.

Global Rationale: The acini cells are contained within the lobules that produce milk. The remaining structures are not responsible for milk production.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae.

Question 18

Type: MCSA

During the breast examination on a client, the nurse palpates a small, subclavicular node on the right side of the clients chest. The priority action at this time is for the nurse is to do which of the following?

1. Call the primary care provider.

2. Ask the client if they have a family history of breast cancer.

3. Continue with the exam.

4. Schedule a mammogram for the next available appointment.

Correct Answer: 3

Rationale 1: Calling the primary care provider should not occur until the exam is complete. This will allow for all information, such as the size and location of any and all palpable masses, as well as subjective information from the client to be reported to the primary care provider.

Rationale 2: Asking the client at this point in the examination if she has a family history of breast cancer would most likely alarm the client that there is something wrong. This question should be asked during the client interview.

Rationale 3: Usually nodes are nonpalpable, but subclavicular nodes must be assessed as part of the examination. It would be important for the nurse to complete the exam, in order to document size, location of any and all palpable masses. Documentation of the clients report to corroborate findings is also important. Reporting these findings in completeness to the primary care provider would be the next step, and any further follow-up would be determined by that provider, along with the clients input.

Rationale 4: Scheduling a mammogram for the next available appointment would be inappropriate at this point. The examination should be completed and all information reported to the primary care provider, who will determine, with the input of the client, the necessity of scheduling a mammogram.

Global Rationale: Usually nodes are nonpalpable, but subclavicular nodes must be assessed as part of the examination. It would be important for the nurse to complete the exam, in order to document size, location of any and all palpable masses. Documentation of the clients report to corroborate findings is also important. Reporting these findings in completeness to the primary care provider would be the next step, and any further follow-up would be determined by that provider, along with the clients input.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 19

Type: HOTSPOT

The nurse is preparing a poster on selfbreast examination and is labeling the anatomical structures of the breast. Identify the area that the nurse should label as the tail of Spence.

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The tail of Spence, also called the axillary tail, is the portion of breast tissue that expends superiolaterally into the axilla.

Global Rationale:

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae.

Question 20

Type: MCMA

The nurse is planning to perform a breast examination of a female client. In preparing the client, the nurse will inform the client to expect which of the following techniques?

Standard Text: Select all that apply.

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

5. Client interview

Correct Answer: 1,2,5

Rationale 1: Inspection, Inspection involves looking at skin color, structures of the breast, and the appearance of the axillae

Rationale 2: Palpation, Palpation involves feeling the breast tissue, nipples, and axillary regions for any abnormalities.

Rationale 3: Percussion, Percussion is a physical assessment technique that is not necessary for breast tissue.

Rationale 4: Auscultation, Auscultation is a physical assessment technique that is not necessary for breast tissue.

Rationale 5: Client interview, The client interview is necessary in order to obtain subjective information regarding the clients state of breast health or illness.

Global Rationale: Inspection, palpation, and the client interview are necessary for a complete assessment of the breasts. Percussion and auscultation are not assessment techniques used on breast tissue.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.3: Explain client preparation for examination of the breasts and axillae.

Question 21

Type: MCSA

While the nurse is counseling a client about fibrocystic breast disease, the client asks if having this disorder will lead to cancer. The nurses best response is:

1. There is no direct link between this disease and breast cancer.

2. You will need to ask the primary healthcare provider that question.

3. This disease is a form of cancer.

4. Why are you so worried about this?

Correct Answer: 1

Rationale 1: This is the most appropriate response since research indicates that no direct link has been found between fibrocystic disease and breast cancer. However, the primary health care provider will want to monitor the client with fibrocystic breast disease because some clients with the disease develop ductal hyperplasia and dysplasia, which may eventually develop into noninvasive intraductal, lobular, or intraepithelial carcinoma.

Rationale 2: You will need to ask the primary care provider that question is inappropriate because this statement does not address the clients question.

Rationale 3: Fibrocystic breast disease is a thickening of the normal breast tissue, which may be accompanied by cyst formation. The statement This disease is a form of cancer is incorrect.

Rationale 4: Why are you so worried about this? is not an appropriate statement as it disregards the clients feelings.

Global Rationale: There is no direct link between fibrocystic disease and the incidence of cancer. The disease is not a form of cancer, and the remaining two choices do not address the clients concerns.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and cultural variation that guide assessment.

Question 22

Type: MCSA

The nurse working in a predominately Hispanic community outlines a breast health screening. The nurse is aware that:

1. Breast cancer is the leading cause of cancer death in Hispanic women.

2. This cultural group is strict about performing monthly self breast exams.

3. Hispanic women have a higher incidence of breast cancer after age 40.

4. Hispanic women have an open attitude about private issues.

Correct Answer: 1

Rationale 1: While Hispanic women, along with Asian women, have the lowest rates of breast cancer, breast cancer is the leading cause of cancer death in Hispanic women.

Rationale 2: It is common for this particular cultural group to believe that looking at or touching themselves is prohibited; therefore, this culture is not strict about performing monthly selfbreast exams.

Rationale 3: Caucasian women over the age of 40 have a higher incidence of breast cancer than women in all other racial and ethnic groups.

Rationale 4: Many Hispanic women do not have an open attitude about private issues. Females in many cultures have concerns about discussing breast health or disease, as well as disrobing and being examined by others, especially when the examiner is of the opposite sex.

Global Rationale: Breast cancer is the leading cause of cancer death in Hispanic women, and it is common for this particular cultural group to believe that looking at or touching themselves is prohibited. Caucasian women have a higher incidence of breast cancer after age 40 than do women in other racial and ethnic groups.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts.

Question 23

Type: HOTSPOT

The nurse is aware that the client with breast cancer is most at risk for metastasis of the disease through the lymphatic system. Identify which lymph nodes are most responsible for the spread of breast cancer via the lymphatic system:

Screen Shot 2015-09-24 at 12.21.37 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The internal mammary nodes drain toward the abdomen and the opposite breast. Most of the lymph from the rest of the breast drains toward the axilla and subclavicular region. Therefore, cancer within the breast can spread through the lymphatic system via the subclavicular nodes, into deep channels within the chest or abdomen, and even to the opposite breast.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.1: Identify the anatomy and physiology of the breasts and axillae.

Question 24

Type: MCSA

The mother of a 9-year-old girl voices concern to the nurse regarding her daughters breast development and breast tenderness. The nurses best response to the mother is:

1. I understand your concern. 9 years old is very young for your daughters breasts to be developing. Children this age are not equipped to deal with these changes.

2. I will let her primary care provider know that an exam is necessary due to your daughters symptoms.

3. I wouldnt worry about it unless the tenderness continues or worsens.

4. Breast enlargement and tenderness is common between the ages of 9 to 13, but I will inform her primary care provider of your concerns.

Correct Answer: 4

Rationale 1: I understand your concern. 9 years old is very young for your daughters breasts to be developing. Children this age are not equipped to deal with these changes, is incorrect since 9 years old is not too young for female breast development, and if proper information is given to the girl she will be able to deal with these changes.

Rationale 2: I will let her primary care provider know that an exam is necessary due to your daughters symptoms, does not directly address the mothers concerns; rather, it will instill more fear as this statement will lead the mother to believe there may be a problem.

Rationale 3: I wouldnt worry about it unless the tenderness continues or worsens, disregards the mothers concerns, and although these symptoms are common for this age, the primary care provider should be aware of the situation.

Rationale 4: Breast enlargement and tenderness is common between the ages of 9 to 13, but I will inform her primary care provider of your concerns, is the best response because it directly answers the concerns of the mother with facts, and the primary care provider will be made aware of the situation.

Global Rationale: Breast enlargement and tenderness commonly begins with the onset of puberty, which is usually between the ages of 9 to 13. Letting the primary care provider know the mothers concerns addresses the worry the mother is experiencing. Responses 2 and 3 do not properly address the mothers concerns.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.7: Identify anatomic, physiologic, developmental, psychosocial, and cultural variation that guide assessment.

Question 25

Type: MCSA

The nurse is performing a breast assessment of an Asian adult female. Which of the following should the nurse do first?

1. Ask the client if she has ever had any breast disease such as cancer of the breast, fibrocystic disease, or fibroadenoma.

2. Ask the client to disrobe from the waist up and place a gown on with the opening to the front.

3. Ask the client if she has noticed any changes in her breasts such as lumps, thickening, or discharge from the nipples.

4. Ask the client how she feels about her breasts.

Correct Answer: 3

Rationale 1: Initially asking the Asian client about breast disease may be too aggressive in the interview process and make the client feel uncomfortable about such issues.

Rationale 2: Asking the client to disrobe as one of the initial steps in the interview process does not allow for rapport to be established, especially with a client from this culture.

Rationale 3: Asking the client if she has noticed any changes in her breasts would be a more effective way to lead into the entire breast assessment process and lead to developing rapport with the client.

Rationale 4: Asking an Asian client how she feels about her breasts in the first stage of the assessment process would likely block communication and make the client feel uncomfortable about the assessment.

Global Rationale: Asking the client if she has noticed any changes in her breasts may open up rapport with this client. Females of Asian descent are often stoic and do not seek preventive care so this would be a good way to lead into the entire focus assessment and physical exam. Immediately asking her questions about breast disease, how she feels about her breasts, or having her disrobe would likely be uncomfortable for a client from this culture.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.3: Explain client preparation for examination of the breasts and axillae.

Question 26

Type: MCSA

The nurse is teaching a childbirth education class. The nurse would be correct in stating that which of the following commonly leaks from the nipples during the last month of pregnancy?

1. Blood

2. Milk

3. Serum

4. Colostrum

Correct Answer: 4

Rationale 1: It is not normal for blood to be discharged from the nipples. This is often a sign of cancer of the breast.

Rationale 2: Milk is not discharged from the breast until lactation following delivery occurs.

Rationale 3: Serous discharge may be a symptom of benign breast disease or cancer of the breast. Discharge from the nipples may be clear, straw colored, milky, or green with benign breast disease, and discharge may be clear or bloody with cancer of the breast.

Rationale 4: Colostrum is a form of milk produced by the mammary glands toward the end of pregnancy, and it is normal for some to leak from the nipples. It appears as a thick yellow discharge.

Global Rationale: Colostrum is a form of milk produced by the mammary glands toward the end of pregnancy, and it is normal for some to leak from the nipples. Its appearance is a thick yellow discharge. The other options are not a normal occurrence at the end of a pregnancy.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 16.7: Identify anatomical, physiologic, developmental, psychosocial, and cultural variation that guide assessment.

Question 27

Type: MCMA

During a health assessment, a male client voices concern that he is at risk for breast cancer. The nurse is aware that further evaluation of the clients history should focus on predisposing factors that increase the chance for breast cancer in males. The interview should include questions related to which of the following factors?

Standard Text: Select all that apply.

1. Previous history of taking testosterone

2. The clients mother having a history of breast cancer

3. History of cirrhosis of the liver

4. History of kidney disease

5. History of radiation treatment for lung cancer

Correct Answer: 2,3,5

Rationale 1: Previous history of taking testosterone. Previously taking testosterone does not increase the risk of male breast cancer. Estrogen therapy in males does increase the risk for male breast cancer.

Rationale 2: The clients mother having a history of breast cancer. A family history of breast cancer in primary female relatives, such as a mother, does increase the risk for male breast cancer.

Rationale 3: History of cirrhosis of the liver. Cirrhosis of the liver has been found to increase the risk for male breast cancer.

Rationale 4: History of kidney disease. A history of kidney disease is not a predisposing factor for male breast cancer.

Rationale 5: History of radiation treatment for lung cancer. Radiation exposure, such as radiation therapy for lung cancer, increases the risk for male breast cancer.

Global Rationale: Predisposing factors for breast cancer in the male population include radiation exposure, cirrhosis, estrogen medications, and a history of breast cancer in primary female relatives. Taking testosterone and kidney disease are not predisposing factors for male breast cancer.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 16.2: Develop questions to be used when completing the focused interview.

Question 28

Type: MCSA

During the focused assessment of a female client, she reports breast tenderness, swelling, and lymph node enlargement around the time of her period. The nurses best response to this finding is:

1. This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly.

2. Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider.

3. As long as you have not detected any lumps you have nothing to worry about.

4. Do you have a history of fibrocystic breast disease? These symptoms are usually seen with this disease.

Correct Answer: 2

Rationale 1: Nodularity is a benign physiologic condition of lumps in the breasts that occur just prior to the menstrual period through the end of the period. The client in this scenario does not report any lumps.

Rationale 2: Fluctuating hormone levels frequently cause these symptoms, along with breast pain. Contraceptives can also cause these symptoms. The nurse is also correct in documenting the symptoms and informing the primary care provider so that further evaluation can occur.

Rationale 3: As long as you have not detected any lumps you have nothing to worry about, does not validate the information the client is reporting, nor does it help to tell the client not to worry. In addition, this response may lead the client to believe that only lumps would be of significance to report.

Rationale 4: While fibrocystic breast disease frequently coincides with fluctuating hormone levels of menstruation, its symptoms vary in that along with painful breasts, the client will have masses upon palpation that feel soft, well demarcated, and freely movable. These masses are usually found bilaterally. Clear, straw colored, milky, or green discharge from the nipples may also occur.

Global Rationale: Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider is the best response since these are typical symptoms associated with the fluctuation of hormone levels during menses, but should still be reported. Nodularity is a benign condition, but the client does not mention any nodules being present. Stating As long as you have not detected any lumps you have nothing to worry about, may lead the client to feel that complaints are not justified unless lumps are present. Fibrocystic breast disease is seen with fluctuation of hormone levels with menses but typically has several other symptoms in addition to breast pain, including bilateral masses upon palpation that feel soft, well demarcated, and freely movable, and clear, straw colored, milky, or green discharge from the nipples.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.2: Develop questions to be used when completing the focused interview.

Question 29

Type: MCMA

While the nurse is performing an assessment of a male client, gynecomastia is noted. The nurse is aware that this condition is most frequently associated with:

Standard Text: Select all that apply.

1. cancer of the breast in male clients.

2. infants following birth.

3. the onset of puberty.

4. older males that have undergone hormonal treatment.

5. infection of breast tissue.

Correct Answer: 2,3,4

Rationale 1: Cancer of the breast in male clients. Cancer of the breast in males typically manifests as a hard nodule fixed to the nipple and underlying tissue, and nipple discharge may be present. Breast enlargement is not a typical symptom of breast cancer in males.

Rationale 2: Infants following birth. Gynecomastia is a temporary condition of breast enlargement in males, and is commonly seen in infants following birth.

Rationale 3: The onset of puberty. Gynecomastia is a temporary condition of breast enlargement in males that is sometimes seen at the onset of puberty, and may occur in one or both breasts.

Rationale 4: Older males that have undergone hormonal treatment. Gynecomastia is a temporary condition of breast enlargement in males that may be seen in older adult males; especially those that have received hormonal treatment for prostate cancer.

Rationale 5: Infection of breast tissue. Infection of breast tissue is not generally associated with gynecomastia.

Global Rationale: Gynecomastia is a temporary condition of breast enlargement in males. It is most commonly seen in infants, at puberty, and in older males. In older males it may accompany hormonal treatment for prostate cancer. Cancer of the breast in males typically manifests as a hard nodule fixed to the nipple and underlying tissue, and nipple discharge may be present. Gynecomastia is not associated with infection of the breast.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 16.5: Differentiate normal from abnormal findings in physical assessment of the breasts and axillae.

Question 30

Type: MCSA

A female client asks the nurse when the best time is to perform self-breast examination (SBE). The nurses best response is:

1. If you are still menstruating the best time is about 5 days after your period begins each month.

2. If you are postmenopausal the best time is at the beginning of each month.

3. It doesnt really matter as long as you keep a record of when you perform the exam.

4. Your primary care provider can tell you when the best time is for you.

Correct Answer: 1

Rationale 1: If you are still menstruating the best time is about 5 days after your period begins each month, is the best response since there is less hormonal influences on the breast tissue at this time, and it provides a consistent timetable for SBE.

Rationale 2: If you are postmenopausal the best time is at the beginning of each month, is an inaccurate statement. There is no benefit to performing SBE at the beginning of each month, as long as the client performs SBE at the same time each month.

Rationale 3: It doesnt really matter as long as you keep a record of when you perform the exam, is an inaccurate statement. The client should perform SBE at the same time each month for consistency.

Rationale 4: Your primary care provider can tell you when the best time is for you is an inaccurate statement since it is not necessary for the primary care provider to set a schedule for the client to perform SBE.

Global Rationale: For females who are still menstruating, 5 days after the period begins is the best time to perform SBE on a monthly basis since there is less hormonal influences on the breast tissue at this time, and it provides a consistent timetable for SBE. If the female is postmenopausal there is no benefit to performing SBE at the beginning of each month, as long as she performs SBE at the same time each month. It is not necessary for the primary care provider to set a schedule for the client to perform SBE.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as they relate to issues of female breasts.

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