When assessing lymph nodes associated with the breast, which findings should the nurse consider abnormal? (Select all that apply.)

Rationale:

A. Telling the patient to calm down in a directive or commanding way is non-therapeutic. It may increase anxiety, create defensiveness, and hinder communication. This approach does not validate the patient’s feelings or support a collaborative interaction.

B. Asking the patient to stop talking quickly because the nurse cannot understand them focuses on the nurse’s needs rather than the patient’s feelings. It is judgmental and non-therapeutic, and it may make the patient feel dismissed or unheard.

C. While this response acknowledges the patient’s nervousness, emphasizing the need to hurry is not therapeutic. It increases pressure on the patient and may exacerbate anxiety, rather than helping them slow down and organize their thoughts.

D. This response demonstrates therapeutic communication by validating the patient’s feelings ("I can see you're feeling anxious"), providing reassurance, and encouraging a collaborative approach ("Take your time, and we can go through this together"). It creates a supportive environment that helps the patient feel heard and safe, promoting more effective communication.

Rationale:

A. Multiple open lesions on the lower legs are abnormal and may indicate infection, trauma, vascular compromise, or chronic conditions such as venous stasis ulcers. This finding requires further assessment and intervention, so it is not an expected skin finding.

B. Cyanosis around the lips indicates hypoxia or decreased oxygenation and is an abnormal finding. This requires immediate evaluation of the client’s respiratory and cardiovascular status. Cyanosis is never considered normal in adults.

C. Intact skin that is evenly pigmented is considered an expected and healthy finding in adults. It indicates that the skin is functioning properly as a protective barrier, has adequate perfusion, and shows no signs of injury, infection, or circulatory compromise.

D. Tented skin turgor indicates dehydration or loss of skin elasticity and is abnormal in adults. Normal skin turgor should return to its original position quickly when pinched. Persistent tenting reflects compromised fluid status or connective tissue changes.