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Breasts and Axillae DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
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Breasts and Axillae DAmico/Barbarito Health & Physical Assessment inNursing,
Breasts and Axillae
DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Question 1
Type: MCMA
The nurse is conducting a breast health workshop for a group of women.
Which of the following would the nurse include in this workshop when
outlining risk factors for breast cancer?
Standard Text: Select all that apply.
1. Caucasian race
2. Positive family history
3. Low socioeconomic status
4. Hormone replacement therapy
5. Female age 35 to 40
Correct Answer: 1,2,3,4
Rationale 1: Caucasian race. Caucasian females, especially over the age
of 40 have a higher risk of developing breast cancer than any other race or
ethnic group.
Rationale 2: Positive family history. A positive family history of breast
cancer places an individual at a higher risk of developing breast cancer. The
individual is at an even greater risk if the family member developed breast
cancer prior to menopause.
Rationale 3: Low socioeconomic status. Lower socioeconomic status
places an individual at risk for breast cancer for a number of reasons,
including lack of education on preventative measures and diagnostic
recommendations; fear that breast cancer is not treatable and has a high
mortality rate, thus they avoid diagnosis; and the mother of the family in
lower socioeconomic groups often places her familys health care needs
above hers.
Rationale 4: Hormone replacement therapy. Hormone replacement
therapy is linked to higher incidence of breast cancer.
,Breasts and Axillae DAmico/Barbarito Health & Physical Assessment in
Nursing,
Rationale 5: Female age 35 to 40. Females between the ages of 35 to 40
have not been found to have a high incidence of breast cancer.
Global Rationale: Caucasian females over the age of 40, positive family
history, low socioeconomic status, and taking hormone replacement therapy
are risk factors for breast cancer. Females from 35 to 40 years of age are not
at a high risk for developing breast cancer.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 16.6: Discuss objectives in Healthy People 2020 as
they relate to issues of female breasts.
Question 2
Type:
MCSA
The nurse is performing an assessment on a newborn and notes a thin, milky
discharge from the infants nipple. The nurse knows this is a:
1. congenital anomaly.
2. highly irregular finding.
3. reason to call in a specialist.
4. common finding in newborns.
Correct Answer: 4
Rationale 1: The breast tissue of newborns is sometimes swollen because
of hyperestrogenism of pregnancy, and some infants may produce a thin
discharge called witchs milk, which subsides as the infants body eliminates
maternal hormones. This is not considered a congenital anomaly.
Rationale 2: The breast tissue of newborns is sometimes swollen because
of hyperestrogenism of pregnancy, and some infants may produce a thin
discharge called witchs milk, which subsides as the infants body eliminates
maternal hormones; therefore, this is not considered an irregular finding.
Rationale 3: The breast tissue of newborns is sometimes swollen because
of hyperestrogenism of pregnancy, and some infants may produce a thin
discharge called witchs milk, which subsides as the infants body eliminates
,Breasts and Axillae DAmico/Barbarito Health & Physical Assessment in
Nursing,
maternal hormones; therefore, there would be no reason to contact a
specialist.
Rationale 4: The breast tissue of newborns is sometimes swollen because
of hyperestrogenism of pregnancy, and some infants may produce a thin
discharge called witchs milk, which subsides as the infants body eliminates
maternal hormones; therefore, this assessment finding is common in
newborns.
Global Rationale: The breast tissue of newborns is sometimes swollen
because of hyperestrogenism of pregnancy. Some infants may produce a
thin discharge called witchs milk, which subsides as the infants body
eliminates maternal hormones. This is neither irregular nor hereditary, and
there is no reason to call on a specialist.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 16.5: Differentiate normal from abnormal findings in
physical assessment of the breasts and axillae.
Question 3
Type:
MCSA
A female client is hospitalized with injury and tissue destruction of the left
pectoralis major and serratus anterior muscles due to a motor vehicle
accident. The nurse would include which of the following information during
the discharge teaching?
1. Prosthestic devices
2. Support bras
3. Plastic surgery
4. Physical therapy
Correct Answer: 2
Rationale 1: A prosthetic device is not indicated as treatment in this
scenario, so discharge teaching for such devices is not necessary.
Rationale 2: Discharge teaching regarding the need for the client to wear a
, Breasts and Axillae DAmico/Barbarito Health & Physical Assessment in
Nursing,
support bra would be indicated in this scenario since injury has occurred to
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