NUR 245 Exam 3 Test Bank Ques
Update) Questions and Verified Answers |
100% Correct | Grade A
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place
them at a higher risk for breast cancer?
a. 37 year old who is slightly overweight
b. 42 year old who has had ovarian cancer
c. 45 year old who has never been pregnant
d. 65 year old whose mother had breast cancer
ANSWER✔✔ D
Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or
daughter) and being older than 50 years of age
.
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right
breast. Which of these statements is true about this finding?
a. Breasts should always be symmetric.
b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.
c. Asymmetry is not unusual, but the nurse should verify that this change is not new.
d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or
growth.
ANSWER✔✔ C
The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size;
often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies
inflammation or new growth.
.
,The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the
inspection phase of breast examination?
a. Woman whose nipples are in different planes (deviated).
b. Woman whose left breast is slightly larger than her right.
c. Nonpregnant woman whose skin is marked with linear striae.
d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin.
ANSWER✔✔ A
The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in
pointing, an underlying cancer may cause fibrosis in the mammary ducts, which pulls the nipple angle
toward it. The other examples are normal findings
.
During the physical examination, the nurse notices that a female patient has an inverted left nipple.
Which statement regarding this is most accurate?
a. Normal nipple inversion is usually bilateral.
b. Unilateral inversion of a nipple is always a serious sign.
c. Whether the inversion is a recent change should be determined.
d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
ANSWER✔✔ C
The nurse should distinguish between a recently retracted nipple from one that has been inverted for
many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be
pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired disease
.
The nurse is performing a breast examination. Which of these statements best describes the correct
procedure to use when screening for nipple and skin retraction during a breast examination? Have the
woman:
a. Bend over and touch her toes.
b. Lie down on her left side and notice any retraction.
,c. Shift from a supine position to a standing position, and note any lag or retraction.
d. Slowly lift her arms above her head, and note any retraction or lag in movement.
ANSWER✔✔ D
The woman should be directed to change position while checking the breasts for signs of skin retraction.
Initially, she should be asked to lift her arms slowly over her head. Both breasts should move up
symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing
neoplasms. The nurse should notice whether movement of one breast is lagging.
The nurse is palpating a female patients breasts during an examination. Which of these positions is most
likely to make significant lumps more distinct during breast palpation?
a. Supine with the arms raised over her head
b. Sitting with the arms relaxed at her sides
c. Supine with the arms relaxed at her sides
d. Sitting with the arms flexed and fingertips touching her shoulders
ANSWER✔✔ A
The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated,
and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and
medially displace it. Any significant lumps will then feel more distinct.
.
Which of these clinical situations would the nurse consider to be outside normal limits?
a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her
breast examination reveals breasts that are soft and slightly sagging.
b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have
a firm, transverse ridge along the lower quadrant in both breasts.
c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast
examination reveals breast tissue that is nodular and somewhat engorged. She states that the
examination was slightly painful.
d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now
10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small
amount of thick yellow discharge from both nipples.
, ANSWER✔✔ D
If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and
lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and
elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and
consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm,
transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is
especially noticeable in large breasts.
.
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was
on her left breast near her axilla. The nurse should plan to:
a. Palpate the lump first.
b. Palpate the unaffected breast first.
c. Avoid palpating the lump because it could be a cyst, which might rupture.
d. Palpate the breast with the lump first but plan to palpate the axilla last.
ANSWER✔✔ B
If the woman mentions a breast lump she has discovered herself, then the nurse should examine the
unaffected breast first to learn a baseline of normal consistency for this individual.
The nurse has palpated a lump in a female patients right breast. The nurse documents this as a small,
round, firm, distinct, lump located at 2 oclock, 2 cm from the nipple. It is nontender and fixed. No
associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed.
What information is missing from the documentation?
a. Shape of the lump
b. Consistency of the lump
c. Size of the lump
d. Whether the lump is solitary or multiple
ANSWER✔✔ C
If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location, (2) size
judge in centimeters in three dimensions: width length thickness, (3) shape, (4) consistency, (5) motility,
(6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.
Update) Questions and Verified Answers |
100% Correct | Grade A
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place
them at a higher risk for breast cancer?
a. 37 year old who is slightly overweight
b. 42 year old who has had ovarian cancer
c. 45 year old who has never been pregnant
d. 65 year old whose mother had breast cancer
ANSWER✔✔ D
Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or
daughter) and being older than 50 years of age
.
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right
breast. Which of these statements is true about this finding?
a. Breasts should always be symmetric.
b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.
c. Asymmetry is not unusual, but the nurse should verify that this change is not new.
d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or
growth.
ANSWER✔✔ C
The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size;
often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies
inflammation or new growth.
.
,The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the
inspection phase of breast examination?
a. Woman whose nipples are in different planes (deviated).
b. Woman whose left breast is slightly larger than her right.
c. Nonpregnant woman whose skin is marked with linear striae.
d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin.
ANSWER✔✔ A
The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in
pointing, an underlying cancer may cause fibrosis in the mammary ducts, which pulls the nipple angle
toward it. The other examples are normal findings
.
During the physical examination, the nurse notices that a female patient has an inverted left nipple.
Which statement regarding this is most accurate?
a. Normal nipple inversion is usually bilateral.
b. Unilateral inversion of a nipple is always a serious sign.
c. Whether the inversion is a recent change should be determined.
d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
ANSWER✔✔ C
The nurse should distinguish between a recently retracted nipple from one that has been inverted for
many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be
pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired disease
.
The nurse is performing a breast examination. Which of these statements best describes the correct
procedure to use when screening for nipple and skin retraction during a breast examination? Have the
woman:
a. Bend over and touch her toes.
b. Lie down on her left side and notice any retraction.
,c. Shift from a supine position to a standing position, and note any lag or retraction.
d. Slowly lift her arms above her head, and note any retraction or lag in movement.
ANSWER✔✔ D
The woman should be directed to change position while checking the breasts for signs of skin retraction.
Initially, she should be asked to lift her arms slowly over her head. Both breasts should move up
symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing
neoplasms. The nurse should notice whether movement of one breast is lagging.
The nurse is palpating a female patients breasts during an examination. Which of these positions is most
likely to make significant lumps more distinct during breast palpation?
a. Supine with the arms raised over her head
b. Sitting with the arms relaxed at her sides
c. Supine with the arms relaxed at her sides
d. Sitting with the arms flexed and fingertips touching her shoulders
ANSWER✔✔ A
The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated,
and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and
medially displace it. Any significant lumps will then feel more distinct.
.
Which of these clinical situations would the nurse consider to be outside normal limits?
a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her
breast examination reveals breasts that are soft and slightly sagging.
b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have
a firm, transverse ridge along the lower quadrant in both breasts.
c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast
examination reveals breast tissue that is nodular and somewhat engorged. She states that the
examination was slightly painful.
d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now
10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small
amount of thick yellow discharge from both nipples.
, ANSWER✔✔ D
If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and
lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and
elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and
consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm,
transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is
especially noticeable in large breasts.
.
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was
on her left breast near her axilla. The nurse should plan to:
a. Palpate the lump first.
b. Palpate the unaffected breast first.
c. Avoid palpating the lump because it could be a cyst, which might rupture.
d. Palpate the breast with the lump first but plan to palpate the axilla last.
ANSWER✔✔ B
If the woman mentions a breast lump she has discovered herself, then the nurse should examine the
unaffected breast first to learn a baseline of normal consistency for this individual.
The nurse has palpated a lump in a female patients right breast. The nurse documents this as a small,
round, firm, distinct, lump located at 2 oclock, 2 cm from the nipple. It is nontender and fixed. No
associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed.
What information is missing from the documentation?
a. Shape of the lump
b. Consistency of the lump
c. Size of the lump
d. Whether the lump is solitary or multiple
ANSWER✔✔ C
If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location, (2) size
judge in centimeters in three dimensions: width length thickness, (3) shape, (4) consistency, (5) motility,
(6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.
