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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale: These side effects are not related to spironolactone use.

Choice B rationale: These are common side effects of spironolactone, as it causes potassium retention and sodium loss.

Choice C rationale: These side effects are not related to spironolactone use.

Choice D rationale: These side effects are not related to spironolactone use.

A. Stools constantly oozing from the rectum B. Chronic constipation C. Diarrhea D. Constipation alternating with diarrhea

Correct Answer is C

Explanation

Choice A rationale: Not a typical characteristic of Crohn's disease; more associated with conditions like rectal fistulas.

Choice B rationale: Crohn's disease commonly involves diarrhea rather than chronic constipation.

Choice C rationale: A common symptom of Crohn's disease due to inflammation and malabsorption in the intestines.

Choice D rationale: Crohn's disease typically presents with diarrhea but not necessarily alternating with constipation. Constipation alternating with diarrhea may also occur in irritable bowel syndrome.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects?

Correct Answer is B

Explanation

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record?

Correct Answer is C

Explanation

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