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 ["B","D"]
Explanation
Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.
Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.
Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.
Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.
Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.
Correct Answer is D
Explanation
Choice A rationale: Biopsy during an endoscopy can help confirm the presence of duodenal ulcers by analyzing tissue samples.
Choice B rationale: Urea breath test is used to detect the presence of Helicobacter pylori, a bacterium associated with duodenal ulcers.
Choice C rationale: Endoscopy is a standard procedure for diagnosing duodenal ulcers by directly visualizing the upper gastrointestinal tract.
Choice D rationale: While a CT scan can be useful in some cases, it's less commonly used for diagnosing duodenal ulcers compared to other diagnostic methods like endoscopy,
biopsy, or urea breath test.
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