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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.
Choice B rationale: One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.
Choice C rationale: Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.
Choice D rationale: NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.
Correct Answer is B
Explanation
Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.
Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.
Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.
Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.
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