BREAST AND AXILLA Flashcards
(10 cards)
During a breast assessment, the nurse notes dimpling of the skin over the left breast. What is the most appropriate interpretation of this finding?
A. Normal variation with age
B. Evidence of fibrocystic changes
C. Possible malignancy
D. Sign of inflammation
C. Possible malignancy
Rationale: Skin dimpling may indicate underlying cancer causing fibrous tissue retraction.
A nurse is assessing a female client’s axillary area. Where should the nurse palpate for the central axillary lymph nodes?
A. Along the anterior axillary line
B. Along the posterior axillary fold
C. High in the middle of the axilla
D. Just above the clavicle
C. High in the middle of the axilla
Rationale: The central axillary nodes are located high in the center of the axilla and are commonly palpated during a breast exam.
Which finding during breast examination would require immediate follow-up?
A. Symmetrical nodularity in both breasts
B. Small, mobile, rubbery lump in the outer quadrant
C. One firm, fixed lump with irregular borders
D. Breast tenderness during menstruation
C. One firm, fixed lump with irregular borders
Rationale: A fixed, irregular mass may indicate malignancy and requires prompt evaluation.
A nurse is teaching a client how to perform a breast self-exam. Which of the following techniques is appropriate to include?
A. Perform the exam once every 6 months
B. Use the fingertips to press firmly in a circular motion
C. Inspect the breasts only in a lying position
D. Perform the exam during menstruation
B. Use the fingertips to press firmly in a circular motion
Rationale: Using the pads of the fingers in a circular motion helps detect lumps during self-exams. The best time is 7–10 days after menstruation starts.
A nurse is palpating the axillary lymph nodes. Which finding would be considered normal?
A. A hard, fixed, 2 cm node
B. A tender, enlarged, freely mobile node
C. A 1 cm rubbery, non-tender, freely mobile node
D. Multiple matted nodes with overlying skin changes
C. A 1 cm rubbery, non-tender, freely mobile node
Rationale: Small, mobile, non-tender lymph nodes are normal. Hard, fixed, or tender nodes may indicate infection or malignancy.
Which of the following is a risk factor for breast cancer?
A. Early menopause
B. First pregnancy before age 25
C. Obesity after menopause
D. Breastfeeding for over 12 months
C. Obesity after menopause
Rationale: Postmenopausal obesity increases estrogen levels, raising the risk of breast cancer.
The nurse palpates a tender, soft, movable mass in the upper outer quadrant of the breast. The client reports breast tenderness before menstruation. What is the most likely cause?
A. Breast carcinoma
B. Fibrocystic changes
C. Lipoma
D. Intraductal papilloma
B. Fibrocystic changes
Rationale: Fibrocystic changes often cause tender, movable lumps that vary with the menstrual cycle.
Which is the best position for a female client during the palpation phase of a breast exam?
A. Sitting upright with arms at sides
B. Lying supine with arm overhead on the side being examined
C. Standing with arms crossed over chest
D. Sitting with hands on hips
B. Lying supine with arm overhead on the side being examined
Rationale: Lying supine flattens the breast tissue, making it easier to palpate for masses.
Which of the following statements made by a client indicates correct understanding of breast self-exam?
A. “I will do my exam a week before my period.”
B. “I should use my fingernails to check for lumps.”
C. “I will do the exam monthly, after my period ends.”
D. “If I find a lump, I’ll wait to see if it goes away before calling the doctor.
C. “I will do the exam monthly, after my period ends.”
Rationale: The ideal time is 7–10 days after menstruation starts when hormonal influence on the breasts is minimal.
During inspection of a female client’s breasts, the nurse asks her to raise her arms overhead. What is the rationale for this action?
A. To inspect for changes in size and color
B. To enhance visualization of the nipple
C. To check for nipple discharge
D. To observe for symmetry and skin retraction
D. To observe for symmetry and skin retraction
Rationale: Raising the arms may reveal subtle differences or retractions not visible in a relaxed position.
