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 the accurate amount of fluid intake by the patient.

Choice B rationale: This is less than the total fluid intake by the patient.

Choice C rationale: This is less than the total fluid intake by the patient.

Choice D rationale: This is correct.( This is the sum of the intravenous fluid, the water, and the chicken broth, converted to milliliters: 650 + (6 x 30) + (8 x 30) = 1070.)

A. Determine if blood is present in urine B. Perform a neurological assessment C. Administer IV normal saline D. Perform a 12-lead electrocardiogram

Correct Answer is C

Explanation

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

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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.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Correct Answer is C

Explanation

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.)

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