After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

Peau d'orange

Skin ulceration

Nipple retraction

Nontender axillary nodes

Mobile mass at 2 o'clock

Dense breast tissue

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A rationale: This is a condition where the skin of the breast becomes dimpled and resembles an orange peel. It is caused by blockage of the lymphatic vessels by cancer cells or inflammation.

Choice B rationale: This is a condition where the skin of the breast breaks down and forms an open sore. It can be a sign of advanced or inflammatory breast cancer.

Choice C rationale: This is a condition where the nipple becomes inverted or pulled inward. It can be caused by scarring, infection, or cancer in the breast tissue or ducts.

Choice D rationale: These are lymph nodes in the armpit that are enlarged and hard but not painful. They can be a sign of cancer spreading from the breast to the lymphatic system.

Choice E rationale: This is a lump in the breast that can be felt and moved around. It is located at the upper outer quadrant of the right breast, as if looking at a clock face. It can be benign or malignant, depending on its size, shape, consistency, and borders.

Choice F rationale: Dense breast tissue is not an abnormal finding that indicates possible breast cancer. It is a normal variation that makes it harder to detect lumps or

abnormalities on mammograms. Women with dense breasts may need additional screening tests such as ultrasound or MRI.

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Correct Answer is D

Explanation

Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.

Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.

Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.

Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.

A. pulmonary embolism B. myocardial infarction C. fat embolism syndrome D. compartment syndrome

Correct Answer is C

Explanation

Choice A rationale: Pulmonary embolism would cause chest pain, dyspnea, and hemoptysis, but not petechiae or neurological changes.

Choice B rationale: While chest pain might be associated with myocardial infarction, the combination of symptoms aligns more with a pulmonary embolism.

Choice C rationale: Fat embolism syndrome occurs when fat globules from the bone marrow enter the bloodstream and travel to the lungs, brain, or other organs. This can

cause respiratory distress, neurological impairment, petechiae (reddish-purple spots on the skin), and cardiac dysfunction.

Choice D rationale: Compartment syndrome doesn't typically manifest with respiratory symptoms or reddish-purple spots.

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After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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