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 A
Explanation
Choice A rationale: Petit mal seizures, also known as absence seizures, involve a sudden lapse in consciousness for a brief duration, typically 5 to 30 seconds.
Choice B rationale: Clonic seizures involve rhythmic jerking movements.
Choice C rationale: Tonic-clonic seizures involve both tonic (muscle stiffness) and clonic (rhythmic jerking) phases.
Choice D rationale: Tonic seizures involve muscle stiffness but don't usually present as sudden lapses of consciousness in a short duration.
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Correct Answer is ["A","C","E"]
Explanation
Choice A rationale: Correct. The statement is accurate because developing confusion could be a sign of a serious condition like severe electrolyte imbalance or dehydration, requiring immediate medical attention.
Choice B rationale: Incorrect. Fluid intake should not be arbitrarily limited without medical advice, especially for a client with diabetes insipidus. Maintaining a consistent fluid intake is crucial, and any changes should be guided by a healthcare provider.
Choice C rationale: Correct. Weighing oneself at the same time every day is a good practice for monitoring fluid balance and identifying sudden changes that may indicate a problem.
Choice D rationale: Incorrect. Desmopressin doses should be administered as prescribed. The medication's administration should be consistent with the healthcare provider's instructions or the medication guide, not arbitrarily altered.
Choice E rationale: Correct. Keeping a log of fluid intake and urine output is important for managing diabetes insipidus effectively and allows for informed adjustments in fluid intake or medication dosage.
Choice F rationale: Incorrect. Adjusting medication dosage without consulting a healthcare provider is not safe. While increased urination is a symptom of diabetes insipidus, the client should consult their healthcare provider if their symptoms persist or worsen, rather than self-adjusting the medication dose.
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