NR 509 Final Exam Questions With
Correct Marking Scheme
A 44-year-old female mathematician presents to clinic with a complaint of a mass
in the right breast. Her partner noticed this mass 2 days ago, and the patient feels
guilty because she has only had one mammogram and does not engage in breast
self-examination (BSE) on any regular basis. She has no family history of breast
cancer, and her prior mammogram was ordered as a routine screening test at age
43 years after a brief discussion with her primary care provider. After a thorough
investigation reveals a benign cyst, what advice should be given to this patient
about screening for breast cancer in her age group?
a. BSE is well evidenced, and all recommending agencies agree that it should be
taught and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a routine
part of annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Force
(USPSTF)
recommendations for her age group and risk factors prior to her current
complaint.
d. Mammography is most sensitive and specific for women in their 40s, when
breast tissue is still dense enough to image accurately.
e. Breast cancer screening is extremely well st
A 42-year-old female website developer presents for an annual preventive
examination with questions about breast cancer screening. She is concerned
about the radiation exposure associated with mammography and is interested in
magnetic resonance imaging (MRI) as a possible alternative for routine screening.
She is otherwise healthy with no family history of breast, ovarian, or colon
cancer. Which of the following is true about MRI as a screening modality for
breast cancer in the general population?
a. Breast cancer screening by MRI has been well studied in the general
population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the
expense of specificity.
c. This patient is an ideal candidate for screening via breast MRI based on current
evidence
d. Women at low lifetime risk of breast cancer (<20%) are recommended to
undergo screening MRI.
,e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening
with breast MRI.
A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple
discharge. This discharge started several weeks ago and has occurred at
irregular intervals since that time. She does not complain of local tenderness,
redness, fever, or any other systemic symptoms aside from slightly irregular
periods over the last few months. On examination, she is able to express a small
amount of discharge, which is sent to the laboratory and found to be consistent
with breast milk but without any signs of blood or pus. Screening laboratories are
also sent, which reveal a normal blood count, metabolic panel, thyroid-
stimulating hormone, and human chorionic gonadotropin (HCG) level. Further
laboratories are still pending. Which of the following is the most likely diagnosis?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
d. Occult pregnancy
e. Prolactinoma
A 22-year-old G0P0 undergraduate student presents to clinic after finding a
breast mass on breast self-examination (BSE) at home. The mass is nontender
without skin changes, erythema, or overlying swelling. She has heard that most
breast cancers are found by patients themselves, and she is very concerned that
she may have breast cancer. Which of the following is true about BSE and self-
detection of breast cancer?
a. Most masses that women find at home and bring to a provider's attention turn
out to be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-
examination.
c. The most likely breast mass this patient is likely to find in herself is an abscess
complicating underlying mastitis.
d. Because of this patient's age, breast masses should not be pursued with
imaging and diagnosis because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity and
specificity for finding cancerous lesions.
A 48-year-old female psychologist presents to clinic with concerns about her
breast cancer risk after an age-matched cousin was recently diagnosed with this
disease. This cousin is the third family member on her father's side in as many
years to be diagnosed with breast cancer, including the patient's own father, who
had surgery and subsequent treatment 3 years ago for breast cancer. The patient
,has little other knowledge of her family history, only that her grandparents
independently arrived from Eastern Europe near the end of World War II and were
among very few members of their family that survived the war. The patient has
read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires
further information about whether this would be appropriate for her. Which of the
following is true about this patient's indications for BRCA testing?
a. Her familial lineage is irrelevant to her risk of BRCA genes and should be
discounted in assessing her risk for these genes.
b. Breast cancer in a male relative does not add significant weight to the decision
to test for the BRCA genes in this patient.
c. The BRCAPRO calculator does not add any further clinical information to this
patient
d. This patient carries several risk factors that together justify BRCA testing.
A 68-year-old former paleontologist presents to clinic with concerns about her
breast cancer risk. Her mother developed the disease in her 50s and died from it
in her 60s. A younger cousin developed the disease a few years ago before the
age of 50 years, but this individual was not tested for the BRCA1 and
BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had
radiation to the chest. She did take hormone replacement therapy for a few years
before data emerged that this may contribute to breast cancer risk. She has had
several abnormal mammograms in her 50s for persistently dense breasts with
subtle findings, but follow-up biopsies never showed any malignant pathology.
Which of the following is true regarding magnetic resonance imaging (MRI)
screening of this patient?
a. No agency recommends breast MRI for a patient such as this one, who has
moderately but not extraordinary risk factors for breast cancer.
b. The U.S. Preventive Services Task Force (USPSTF) recommends against
screening with MRI for patients with such risk factors.
c. Regardless of recommendations, the high sensitivity of breast MRI comes at
the expense of markedlydecreased specificity (i.e., the a
A 66-year-old female museum curator presents for a routine annual examination.
On examination, a notably enlarged supraclavicular lymph node is appreciated on
the right side. The lymph node is nontender and feels firm and rubbery. She
denies any localized or systemic symptoms such as breast lumps, fevers, or
night sweats. She has been taking conjugated estrogen tablets for 9 years since
menopause, though she has not taken progestin compounds since she had a
hysterectomy for heavy bleeding at age 45 years. Which of the following is true
about this presentation of lymphadenopathy?
a. Breast cancer always presents with axillary lymphadenopathy because the
, lymphatics of the breast uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no further
evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius
muscle in the neck.
d. Firm, rubbery lymph nodes are generally considered to be benign.
e. Metastatic breast cancer cells may spread directly into the infraclavicular and
then supraclavicular nodes without first causing notable changes in the axillary
nodes.
A 24-year-old graphic designer presents to clinic with a concern for a breast
mass. A rubbery, mobile, nontender mass is palpated in the right breast as
described by the patient, which is consistent with a firbroadenoma. In describing
the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm
to the left of the nipple. Which of the following would be the most appropriate way
to report this finding?
a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position
from the nipple"
b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer
quadrant"
c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner
quadrant"
d. "Rubbery, mobile, nontender mass located in the left breast, upper outer
quadrant"
e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position
from the nipple"
A 54-year-old female dietician presents for a routine annual examination. On
review of systems, she reports that she has had many breast findings over
several years, including one biopsy with normal pathology. She feels that her
breasts have become far less lumpy since she underwent menopause 3 years
ago. Which of the following is true regarding changes in the breasts with
menopause?
a. Transformation of breasts to primarily fatty tissue with menopause decreases
the sensitivity and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast
density after menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to
decrease in the number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen dose
from endogenous and exogenous sources over the lifetime.
Correct Marking Scheme
A 44-year-old female mathematician presents to clinic with a complaint of a mass
in the right breast. Her partner noticed this mass 2 days ago, and the patient feels
guilty because she has only had one mammogram and does not engage in breast
self-examination (BSE) on any regular basis. She has no family history of breast
cancer, and her prior mammogram was ordered as a routine screening test at age
43 years after a brief discussion with her primary care provider. After a thorough
investigation reveals a benign cyst, what advice should be given to this patient
about screening for breast cancer in her age group?
a. BSE is well evidenced, and all recommending agencies agree that it should be
taught and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a routine
part of annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Force
(USPSTF)
recommendations for her age group and risk factors prior to her current
complaint.
d. Mammography is most sensitive and specific for women in their 40s, when
breast tissue is still dense enough to image accurately.
e. Breast cancer screening is extremely well st
A 42-year-old female website developer presents for an annual preventive
examination with questions about breast cancer screening. She is concerned
about the radiation exposure associated with mammography and is interested in
magnetic resonance imaging (MRI) as a possible alternative for routine screening.
She is otherwise healthy with no family history of breast, ovarian, or colon
cancer. Which of the following is true about MRI as a screening modality for
breast cancer in the general population?
a. Breast cancer screening by MRI has been well studied in the general
population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the
expense of specificity.
c. This patient is an ideal candidate for screening via breast MRI based on current
evidence
d. Women at low lifetime risk of breast cancer (<20%) are recommended to
undergo screening MRI.
,e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening
with breast MRI.
A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple
discharge. This discharge started several weeks ago and has occurred at
irregular intervals since that time. She does not complain of local tenderness,
redness, fever, or any other systemic symptoms aside from slightly irregular
periods over the last few months. On examination, she is able to express a small
amount of discharge, which is sent to the laboratory and found to be consistent
with breast milk but without any signs of blood or pus. Screening laboratories are
also sent, which reveal a normal blood count, metabolic panel, thyroid-
stimulating hormone, and human chorionic gonadotropin (HCG) level. Further
laboratories are still pending. Which of the following is the most likely diagnosis?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
d. Occult pregnancy
e. Prolactinoma
A 22-year-old G0P0 undergraduate student presents to clinic after finding a
breast mass on breast self-examination (BSE) at home. The mass is nontender
without skin changes, erythema, or overlying swelling. She has heard that most
breast cancers are found by patients themselves, and she is very concerned that
she may have breast cancer. Which of the following is true about BSE and self-
detection of breast cancer?
a. Most masses that women find at home and bring to a provider's attention turn
out to be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-
examination.
c. The most likely breast mass this patient is likely to find in herself is an abscess
complicating underlying mastitis.
d. Because of this patient's age, breast masses should not be pursued with
imaging and diagnosis because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity and
specificity for finding cancerous lesions.
A 48-year-old female psychologist presents to clinic with concerns about her
breast cancer risk after an age-matched cousin was recently diagnosed with this
disease. This cousin is the third family member on her father's side in as many
years to be diagnosed with breast cancer, including the patient's own father, who
had surgery and subsequent treatment 3 years ago for breast cancer. The patient
,has little other knowledge of her family history, only that her grandparents
independently arrived from Eastern Europe near the end of World War II and were
among very few members of their family that survived the war. The patient has
read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires
further information about whether this would be appropriate for her. Which of the
following is true about this patient's indications for BRCA testing?
a. Her familial lineage is irrelevant to her risk of BRCA genes and should be
discounted in assessing her risk for these genes.
b. Breast cancer in a male relative does not add significant weight to the decision
to test for the BRCA genes in this patient.
c. The BRCAPRO calculator does not add any further clinical information to this
patient
d. This patient carries several risk factors that together justify BRCA testing.
A 68-year-old former paleontologist presents to clinic with concerns about her
breast cancer risk. Her mother developed the disease in her 50s and died from it
in her 60s. A younger cousin developed the disease a few years ago before the
age of 50 years, but this individual was not tested for the BRCA1 and
BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had
radiation to the chest. She did take hormone replacement therapy for a few years
before data emerged that this may contribute to breast cancer risk. She has had
several abnormal mammograms in her 50s for persistently dense breasts with
subtle findings, but follow-up biopsies never showed any malignant pathology.
Which of the following is true regarding magnetic resonance imaging (MRI)
screening of this patient?
a. No agency recommends breast MRI for a patient such as this one, who has
moderately but not extraordinary risk factors for breast cancer.
b. The U.S. Preventive Services Task Force (USPSTF) recommends against
screening with MRI for patients with such risk factors.
c. Regardless of recommendations, the high sensitivity of breast MRI comes at
the expense of markedlydecreased specificity (i.e., the a
A 66-year-old female museum curator presents for a routine annual examination.
On examination, a notably enlarged supraclavicular lymph node is appreciated on
the right side. The lymph node is nontender and feels firm and rubbery. She
denies any localized or systemic symptoms such as breast lumps, fevers, or
night sweats. She has been taking conjugated estrogen tablets for 9 years since
menopause, though she has not taken progestin compounds since she had a
hysterectomy for heavy bleeding at age 45 years. Which of the following is true
about this presentation of lymphadenopathy?
a. Breast cancer always presents with axillary lymphadenopathy because the
, lymphatics of the breast uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no further
evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius
muscle in the neck.
d. Firm, rubbery lymph nodes are generally considered to be benign.
e. Metastatic breast cancer cells may spread directly into the infraclavicular and
then supraclavicular nodes without first causing notable changes in the axillary
nodes.
A 24-year-old graphic designer presents to clinic with a concern for a breast
mass. A rubbery, mobile, nontender mass is palpated in the right breast as
described by the patient, which is consistent with a firbroadenoma. In describing
the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm
to the left of the nipple. Which of the following would be the most appropriate way
to report this finding?
a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position
from the nipple"
b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer
quadrant"
c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner
quadrant"
d. "Rubbery, mobile, nontender mass located in the left breast, upper outer
quadrant"
e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position
from the nipple"
A 54-year-old female dietician presents for a routine annual examination. On
review of systems, she reports that she has had many breast findings over
several years, including one biopsy with normal pathology. She feels that her
breasts have become far less lumpy since she underwent menopause 3 years
ago. Which of the following is true regarding changes in the breasts with
menopause?
a. Transformation of breasts to primarily fatty tissue with menopause decreases
the sensitivity and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast
density after menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to
decrease in the number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen dose
from endogenous and exogenous sources over the lifetime.
