Chapter 17: Breasts and Axillae

Multiple Choice

1. Montgomery tubercles are most prominent in the breasts of: a. adult males. b. patients with lung disease. c. pregnant women. d. pubertal females.

ANS: C

Montgomery tubercles undergo hypertrophy and become more prominent in the breasts of pregnant and lactating women.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

2. Most women with breast cancer: a. possess the BRCA1 or BRCA2 gene. b. risk increases with aging. c. have a mother who had breast cancer. d. continue to menstruate after age 52.

ANS: B

Of all breast cancers, 77% occur in women older than 50 years. Most women with breast cancer do not possess the BRCA1 or BRCA2 gene. Only 5% to 10% of women with breast cancer are known to have either gene. Most women with breast cancer do not have a mother who had breast cancer. Familial breast cancers occur in 10% to 20% of breast cancer populations. Most women with breast cancer do not continue to menstruate after age 52. Having a later start of menopause does not overshadow the 77% of all breast cancers that occur in women older than 50 years.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Drinking three glasses of wine per week b. Early menopause c. Nulliparity d. Late menarche

3. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?

ANS: C

Nulliparity, or late age at the birth of the first child (after 30 years old), is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

4. If your patient has nipple discharge, you will most likely need a: a. Vacutainer tube. b. glass slide and fixative. c. specimen jar with formaldehyde. d. tape strip to test pH.

ANS: B

A glass slide and fixative are used for microscopic examination of the discharge to identify its cellular makeup.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

5. While examining a 30-year-old woman, you note that one breast is slightly larger than the other. In response to this finding, you should: a. note the finding in the patient s record. b. ask the patient if she has ever had breast cancer. c. tell the patient to get a mammogram as soon as possible. d. tell the patient to get a mammary sonogram as soon as possible.

ANS: A

Often one breast is slightly larger than the other. This is a normal variation and no further intervention is required.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

6. A 23-year-old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your response to this finding is to: a. instruct her that this is a side effect of birth control injection therapy. b. suggest pregnancy testing. c. question her use of tanning beds. d. schedule an appointment with a surgeon.

ANS: B

In light-skinned women, pregnancy produces enlarged breasts with a darker areola. Neither hormonal injections nor the use of tanning beds will change the color of the areola as does pregnancy. Surgical consultation is not necessary.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

7. In patients with breast cancer, peau d orange skin is often first evident: a. in the axilla. b. in the upper inner quadrant. c. on or around the nipple. d. at the inframammary ridge.

ANS: C

The areola is the most common initial site for visualization of peau d orange skin.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

8. A firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40-year-old patient s breast. You should: a. ask the patient if she has a history of breast cancer. b. refer the patient to a surgeon. c. ask the patient to have a mammogram as soon as possible. d. record the finding in the patient s record.

ANS: D

The inframammary ridge thickens and can be felt more easily with age. It is an expected, normal finding, without indications for further action.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

9. When examining axillary lymph nodes, the patient s arm is: a. raised fully above the head. b. extended at the side. c. flexed at the elbow. d. crossed over the chest.

ANS: C

To examine the axilla, support the patient s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

10. Male gynecomastia associated with illicit or prescription drug use can be expected to: a. lessen when the body becomes accustomed to the drug. b. resolve after the drug is discontinued. c. leave permanent breast enlargement when the drug is discontinued. d. cause purulent drainage if left untreated.

ANS: B

Gynecomastia associated with illicit or prescription drug use (e.g., antihypertensive drugs, estrogens, steroids) usually resolves after the offending drug is discontinued and does not require further intervention.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

11. A nursing mother complains that her breasts are tender. You assess hard, shiny, and erythemic breasts bilaterally. You should advise the patient to: a. massage gently and continue nursing. b. apply warm compresses and stop nursing. c. monitor her temperature and restrict fluids. d. sleep wearing a bra and wash her breasts with antibacterial soap.

ANS: A

This patient has mastitis. The aim of treatment is to promote breast drainage. You should not advise the patient to apply warm compresses and stop nursing. Applying warm compresses will not encourage breast milk flow, and stopping nursing will increase the risk of a breast infection turning into a breast abscess. Monitoring her temperature and restricting fluids do not encourage breast milk flow. Sleeping with a bra and washing the breasts with antibacterial soap do not encourage breast milk flow. Only mild soaps are advised; harsh soaps can dry and crack the nipple and compound infection.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

12. You are conducting a clinical breast examination for your 30-year-old patient. Her breasts are symmetric, with bilateral, multiple tender masses that are freely movable and with well-defined borders. You recognize that these symptoms and assessment findings are consistent with: a. fibroadenoma. b. Paget disease. c. cancer. d. fibrocystic changes.

ANS: D

Fibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. A fibroadenoma is usually nontender. Paget disease is an eczema -like condition of the nipple that signals an underlying cancer. Cancer is usually nontender.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Health Promotion and Maintenance

13. Your patient is a nursing mother who asks you to look at a mole she has under her left breast at the inframammary fold. The mole is nontender and soft and has grown in size since she started nursing. There are no other changes to the mole. This mole probably represents an undiagnosed: a. Montgomery tubercle. b. case of Paget disease. c. supernumerary nipple. d. fat necrosis.

ANS: C

Supernumerary nipples usually resemble moles and occur, as this one does, along the milk line. Those that have glandular tissue may enlarge under hormonal influences. They may not be recognized as extra nipples in infants because they are usually small and not well formed.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

14. When conducting a clinical breast examination, the examiner should: a. forgo the examination if the patient has had a recent mammogram. b. keep the patient s breasts completely covered to respect modesty. c. dim the lights to minimize anxiety. d. inspect both breasts simultaneously.

ANS: D

Simultaneous observation of both breasts is essential to detect differences between breast size, symmetry, contour, and skin color.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

Multiple Response

1. Mrs. Weber is a 65-year-old patient who has presented at the clinic with a complaint of a tender breast mass that she discovered during breast self-examination. You have completed a physical examination on Mrs. Weber and have palpated a mass of the right breast in the lower outer quadrant. When providing patient education to Mrs. Weber regarding the breast mass, you will explain that the characteristics of a cancerous mass would be which of the following? (Select all that apply.)

a. Immobile and firm b. Pain on palpation c. Irregular border edges d. Mobile and rubbery e. Nontender

ANS: A, C, E

Characteristics of cancerous breast masses are irregular or stellate, hard, fixed, nontender, and poorly delineated.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential a. Supraclavicular b. Lateral axillary nodes c. Anterior cervical nodes d. Anterior axillary nodes e. Posterior cervical nodes

2. Ms. Lawson is a 41-year-old patient who presents for a routine annual examination. During her breast examination, you are also completing a lymphatic examination. Which of the following lymph nodes are examined during a breast examination? (Select all that apply.)

ANS: A, B, D DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

Multiple Choice

1. Mrs. James is 7 months pregnant and states that she has de eloped a problem ith constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy because of changes in the colorectal areas, such as: a. decreased movement through the colon and increased water absorption from the stool. b. increased movement through the colon and increased salt taken from foods. c. looser anal sphincter and fewer nutrients taken from foods. d. tighter anal sphincter and less iron eliminated in the stool.

ANS: A

Constipation and flatus are more common during pregnancy because the colon is displaced, peristalsis is decreased, and water absorption is increased. Movement through the colon is decreased during pregnancy. The colon does not absorb nutrients. A tighter sphincter tone is not related to pregnancy.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. The family history of a patient with diarrhea and abdominal pain should include inquiry about cystic fibrosis because it is: a. a common genetic disorder. b. one cause of malabsorption syndrome. c. a curable condition with medical intervention. d. the most frequent cause of diarrhea in general practice.

ANS: B

Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple syst ems. In the gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase deficiency. Steatorrhea and abdominal pain from increased gas production are frequent complaints.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. When assessing abdominal pain in a college-age woman, one must include: a. history of interstate travel. b. food likes and dislikes. c. age at completion of toilet training. d. the first day of the last menstrual period.

ANS: D

Exploring abdominal pain complaints in a young woman can reveal multiple causes related to the menstrual cycle, including menstrual pain, ovulation discomfort, and abnormal menses. Asking the patient to tell you the first day of her last menstrual period can help discriminate among these factors. Histor of international tra el and tra eler s diarrhea can be related to abdominal pain, but interstate travel usually does not. Food preferences and age at completion of toilet training are not relevant.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Infants born weighing less than 1500 g are at higher risk for: a. hepatitis A. b. necrotizing enterocolitis. c. urinary urgency. d. pancreatitis.

ANS: B

Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants. It involves infection and inflammation that cause destruction of the bowel, and it becomes more apparent after feedings.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

5. You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient: a. hold his or her breath. b. sit upright. c. flex his or her knees. d. raise his or her head off the pillow.

ANS: C

To help relax the abdominal musculature, it is helpful to place a small pillow under the patient s head and under slightl fle ed knees. The other techniques are not helpful because they increase muscle flexion.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. Mrs. Little is a 44-year-old patient who presents to the office with abdominal pain and fever. During your examination, you ask the patient to raise her head and shoulders while she lies in a supine position. A midline abdominal ridge rises. You document this observation as a(n): a. small inguinal hernia. b. large epigastric hernia. c. abdominal lipoma. d. diastasis recti.

ANS: D

A diastasis recti occurs when the abdominal contents bulge between two abdominal muscles to form a midline ridge as the head is lifted. It has little clinical significance and usually occurs in women who have had repeated pregnancies and in obese patients.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment

MSC: Integrated Process: Communication and Documentation

7. Mr. Robins is a 45-year-old man who presents to the emergency department with a complaint of constipation. During auscultation, you note borborygmi sounds. This is associated with: a. gastroenteritis. b. peritonitis. c. satiety. d. paralytic ileus.

ANS: A

Borborygmi are prolonged loud gurgles that occur with gastroenteritis, early intestinal obstruction, or hunger. Peritonitis and paralytic ileus result in hypoactive bowel sounds. Food satiety does not stimulate growling sounds as does hunger.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. To document absent bowel sounds correctly, one must listen continuously for: a. 30 seconds. b. 1 minute. c. 3 minutes. d. 5 minutes.

ANS: D

Absent bowel sounds are confirmed after listening to each quadrant for 5 minutes.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. Percussion of the abdomen begins with establishing: a. liver dullness. b. spleen dullness. c. gastric bubble tympany. d. overall dullness and tympany in all quadrants.

ANS: D

Percussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. When percussing a spleen, Traube s space is a: a. semilunar region. b. splenic percussion sign. c. left-sided pleural effusion. d. solid mass.

ANS: A

Percussion of the spleen is more difficult because percussion tones elicited may be caused by other conditions. Traube s space is a semilunar region defined b the si th ribs superiorl , the midaxillary line laterally, and the left costal margin inferiorly.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. Your patient is complaining of acute, intense, sharp epigastric pain that radiates to the back and left scapula, with nausea and vomiting. Based on this history, your prioritized physical examination should be to: a. percuss for ascites. b. assess for rebound tenderness. c. inspect for ecchymosis of the flank. d. auscultate for abdominal bruits.

ANS: C

Abdominal pain that radiates to the back could be caused by pancreatitis or a gastric ulcer, gallbladder pain usually radiates to the right or left scapula but not to the back, pancreatitis pain can radiate to the left shoulder or scapula, and nausea and vomiting usually occur with gallbladder, pancreas, or appendix conditions. Pancreatitis is a differential diagnosis for all these symptoms, so begin the examination by inspecting the flanks for the Grey Turner sign, an indication of pancreatitis.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. To assess for liver enlargement in the obese person, you should: a. use the hook method. b. have the patient lean over at the waist. c. auscultate using the scratch technique. d. attempt palpation during deep exhalation.

ANS: C

If the abdomen is obese or distended, or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. An umbilical assessment in the newborn that is of concern is: a. a thick cord. b. umbilical hernia. c. one umbilical artery and two veins. d. pulsations superior to the umbilicus.

ANS: C

Expect two arteries and one vein. A single umbilical artery indicates the possibility of congenital anomalies. A thick cord suggests a well-nourished fetus, an umbilical hernia will generally close spontaneously by 2 years, and pulsations to the abdomen in the epigastric area are common.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Positive psoas sign b. Positive McBurney sign c. Consistent right lower quadrant (RLQ) pain d. Rebound tenderness

14. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition?

ANS: C

A positive psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the RLQ are signs of appendicitis. The absence of pain migration makes appendicitis less likely.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. When using the bimanual technique for palpating the abdomen, you should: a. push down with the bottom hand and the other hand on top. b. push down with the top hand and concentrate on sensation with the bottom hand. c. place the hands side by side and push equally. d. place one hand anteriorly and the other hand posteriorly, squeezing the hands together.

ANS: B

The bimanual technique uses one hand on top of the other. Exert pressure with the top hand while concentrating on sensation with the other hand.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings usually associated with: a. diverticulitis. b. pancreatitis. c. ruptured ovarian cyst. d. splenic rupture.

ANS: A

Only diverticulitis has all these presenting symptoms.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

17. A 51-year-old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to: a. use a topical, over-the-counter hemorrhoid treatment for 1 week. b. exercise and eat more fiber. c. come to the laboratory for a stool guaiac test. d. eat six small meals a day.

ANS: C

Blood in the stool is an abnormal finding that should never be ignored, even if it can be explained by conditions other than colon cancer. She should have her stool checked for blood now as well as annually because she is older than 50 years.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. Costovertebral angle tenderness should be assessed whenever you suspect that the patient may have: a. cholecystitis. b. pancreatitis. c. pyelonephritis. d. ulcerative colitis.

ANS: C

Pyelonephritis is characterized by flank pain and costovertebral angle tenderness.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

19. A mother brings her 2-year-old child for you to assess. The mother feels a lump whenever she fastens the child s diaper. Nephroblastoma is a likel diagnosis for this child hen our physical examination of the abdomen reveals a(n): a. fixed mass palpated in the hypogastric area. b. tender, midline abdominal mass. c. olive-sized mass of the right upper quadrant. d. nontender, slightly movable, flank mass.

ANS: D

A Wilms tumor (nephroblastoma) is the most common intraabdominal tumor of childhood. It presents with hypertension, fever, malaise, and a firm nontender mass deep within the flank that is only slightly movable and is usually unilateral.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. In older adults, overflow fecal incontinence is commonly caused by: a. malabsorption. b. parasitic diarrhea. c. fecal impaction. d. fistula formation.

ANS: C

Constipation with overflow occurs when the rectum contains hard stool and soft feces above a leak around the mass of stool.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Your patient is a 48-year-old woman with complaints of severe cramping pain in the abdomen and right flank. Her past medical history includes a history of bladder calculi. You diagnose her with renal calculi at this time. Which of the following symptoms would you expect with her diagnosis? (Select all that apply.)

a. Abdominal pain on palpation b. Blumberg sign c. Cullen sign d. CVA tenderness e. Fever f. Grey Turner sign g. Hematuria h. Nausea

ANS: A, D, E, G

Abdominal pain on palpation, CVA tenderness, fever, hematuria, and nausea are all signs and symptoms of renal calculi. The Cullen sign is ecchymosis around the umbilicus, the Blumberg sign is rebound tenderness for appendicitis, the Grey Turner sign is ecchymosis in the flanks, and the McBurne sign is rebound tenderness at McBurne s point.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Physiologic Integrity: Reduction of Risk Potential

OBJ: Nursing process diagnosis a. Nausea b. Dullness on percussion c. Rebound tenderness d. Vomiting e. Diarrhea f. Burning pain in epigastrium

2. Your patient returns to the office with multiple complaints regarding her abdomen. Which of the following are objective findings? (Select all that apply.)

ANS: B, C, E, F

Nausea, vomiting and diarrhea, and burning pain in epigastrium are subjective signs. Dullness on percussion and rebound tenderness are objective findings.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Physiologic Integrity: Reduction of Risk Potential

OBJ: Nursing process diagnosis