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 {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Choice A rationale: A three-point gait is used when one leg is weaker or injured and cannot bear weight. The client should place the crutches about 12 inches in front of the feet and lean forward on the crutches. Then, the client should lift the injured leg and
swing the body forward between the crutches, landing on the uninjured leg. The client should not put any weight on the injured ankle, as ordered by the physician.
Choice B rationale: A four-point gait is used when both legs can bear some weight, but one is weaker than the other.
Choice C rationale: A swing-through gait is used when both legs can bear weight, but need assistance with balance and coordination.
Choice D rationale: A two-point gait is used when both legs have equal strength and can bear full weight.
Correct Answer is C
Explanation
Choice A rationale: The patient with type 2 diabetes admitted with pneumonia might not necessarily need insulin therapy to prevent ketoacidosis.
Choice B rationale: Type 2 diabetes doesn't typically involve islet cell antibodies destroying the pancreas's ability to produce insulin.
Choice C rationale: In this scenario, the patient might have enough endogenous insulin to prevent ketosis but could be at risk for hyperosmolar hyperglycemic syndrome due to illness-induced stress.
Choice D rationale: Type 2 diabetes often involves some degree of endogenous insulin secretion, and not all patients require daily insulin injections.
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