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 C
Explanation
Choice A rationale: Typically associated with potassium depletion rather than elevated levels.
Choice B rationale: Furosemide, a loop diuretic, can cause potassium depletion leading to hypokalemia, but it might also cause transient elevations in potassium levels initially. Choice C rationale: Addison disease can cause hyperkalemia, or high potassium, due to decreased renal excretion of potassium and increased retention of sodium and water.
Choice D rationale: Cushing disease can cause hypokalemia, or low potassium, due to increased renal excretion of potassium and decreased reabsorption of sodium and water.
Correct Answer is D
Explanation
Choice A rationale: Symptoms and findings described align more with an acute, severe condition rather than a chronic one.
Choice B rationale: While cholecystitis can present with similar symptoms, the radiation of pain to the back is more indicative of a different condition.
Choice C rationale: Cholelithiasis (gallstones) might cause abdominal pain but typically doesn’t lead to fever and hypotension.
Choice D rationale: Symptoms including severe abdominal pain, radiation to the back, fever, and hypotension suggest acute pancreatitis, a potentially serious condition requiring urgent medical attention.
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