When assessing lymph nodes associated with the breast, which findings should the nurse consider abnormal? (Select all that apply.)
Moveable
Smooth
Non-tender
Hard
Fixed
Correct Answer : D,E
Rationale:
A. Lymph nodes that are freely moveable under the skin are typically normal. Mobility indicates that the node is not infiltrated by fibrotic tissue or malignant cells. Moveable nodes may shift slightly during palpation and are usually soft or rubbery.
B. Smooth lymph nodes are generally normal. Irregular, nodular, or spiculated nodes are more concerning for pathology. Smoothness alone does not indicate abnormality.
C. Non-tender lymph nodes are often normal, particularly if they are small and soft. Tenderness is usually associated with acute infections, such as localized cellulitis or mastitis. Therefore, non-tender nodes in isolation are not considered abnormal.
D. Hard lymph nodes are abnormal. Hardness suggests that the node may be infiltrated with malignant cells or fibrotic tissue, which can occur in breast cancer metastasis or chronic infections. Hard nodes are less compressible and may be associated with an irregular surface.
E. Fixed, immobile lymph nodes are also abnormal. Normal nodes are freely movable; when nodes are adherent to surrounding tissues, it can indicate malignancy, fibrosis, or metastatic spread. Fixed nodes do not shift easily with palpation and require prompt medical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 30 mg, Concentration = 50 mg/1 mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 30 ÷ 50
Step 4: Calculate
= 0.6 mL
Step 5: Round to the nearest tenth
≈ 0.6 mL
Final Answer: 0.6
Correct Answer is D
Explanation
Rationale:
A. The patient's recent travel destinations may be relevant in certain contexts, such as exposure to infectious diseases, but it is not universally essential for understanding the overall health status. It is supplementary information rather than a core component of a comprehensive health history.
B. The patient's foods and dietary preferences provide insight into nutrition and cultural considerations, but they do not directly identify current health risks, disease management, or potential drug interactions. While valuable, this information is not the highest priority for assessing health status.
C. The patient's preferred pharmacy and insurance information are administrative details that facilitate prescription management and billing, but they do not provide clinical insight into the patient’s health. They are important for logistics but not for evaluating medical status.
D. Current medications, including dosage and frequency, are the most critical information to collect. This data provides a clear picture of ongoing treatments, potential side effects, drug interactions, adherence issues, and the management of chronic or acute conditions. Understanding medications is essential for planning safe care, identifying contraindications, and ensuring accurate assessment and intervention.
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