Podcast
Questions and Answers
When interviewing a client about their breast health history, which question is most important to assess their risk of breast cancer?
When interviewing a client about their breast health history, which question is most important to assess their risk of breast cancer?
- How often do you consume caffeine?
- What type of bra do you wear during exercise?
- Do you have a family history of breast cancer? (correct)
- What was your age at first birth?
A client reports a recent onset of dimpling on one breast. What action should the nurse prioritize during the physical exam?
A client reports a recent onset of dimpling on one breast. What action should the nurse prioritize during the physical exam?
- Measure the circumference of both breasts.
- Assess the nipples for symmetry and size.
- Palpate the axillary lymph nodes.
- Inspect both breasts for symmetry, color, and any visible skin changes, including dimpling. (correct)
During a breast examination, the nurse notes a firm, non-tender lump in the upper outer quadrant of the right breast. What is the most appropriate immediate nursing action?
During a breast examination, the nurse notes a firm, non-tender lump in the upper outer quadrant of the right breast. What is the most appropriate immediate nursing action?
- Further assess the lump for size, shape, consistency, mobility, and tenderness, and document the findings. (correct)
- Immediately refer the client for a mammogram.
- Document the findings and schedule a follow-up appointment in six months.
- Reassure the client that most lumps are benign.
When teaching a client about breast self-examination (BSE), which instruction is most accurate?
When teaching a client about breast self-examination (BSE), which instruction is most accurate?
A client reports chronic use of hormone replacement therapy (HRT). How should this information influence the nurse's assessment?
A client reports chronic use of hormone replacement therapy (HRT). How should this information influence the nurse's assessment?
During palpation of the axillary lymph nodes, the nurse notes enlarged, tender nodes. Which question is most relevant?
During palpation of the axillary lymph nodes, the nurse notes enlarged, tender nodes. Which question is most relevant?
A patient who had a mastectomy five years ago comes in for a routine checkup. Which of the following is the most appropriate action?
A patient who had a mastectomy five years ago comes in for a routine checkup. Which of the following is the most appropriate action?
A nurse is about to perform a clinical breast examination. Which of the following steps should the nurse perform first?
A nurse is about to perform a clinical breast examination. Which of the following steps should the nurse perform first?
When assessing a client with large pendulous breasts, what instruction should the nurse provide to ensure a thorough examination?
When assessing a client with large pendulous breasts, what instruction should the nurse provide to ensure a thorough examination?
During a breast examination, a nursing student asks why it's important to assess the supraclavicular area. What is the nurse's best response?
During a breast examination, a nursing student asks why it's important to assess the supraclavicular area. What is the nurse's best response?
Flashcards
Breast Changes
Breast Changes
Changes in breast lumps, swelling, redness, warmth, dimpling, size, firmness, pain, or discharge.
Past Breast Issues
Past Breast Issues
Past breast problems, including treatments and surgeries.
Age at Menses
Age at Menses
The age when menstruation began.
Age at Menopause
Age at Menopause
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Given Birth
Given Birth
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Age at First Birth
Age at First Birth
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Menstrual Cycle Dates
Menstrual Cycle Dates
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Family Breast Cancer
Family Breast Cancer
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Hormone/Drug Use
Hormone/Drug Use
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Environmental Exposure
Environmental Exposure
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Study Notes
- Assessing Breasts and Lymphatic System involves collecting subjective and objective data via a nursing interview and physical examination.
Nursing Interview Guide: Subjective Data
- Inquire about current symptoms like changes in the breasts including lumps, swelling, redness, warmth, dimpling, size, firmness, pain, or discharge.
- Gather information on past breast problems including treatments and surgeries.
- Determine the patient's age at menses and menopause, if applicable.
- Ask if the patient has given birth and the age at first birth.
- Determine the first and last day of the patient's last menstrual cycle.
- Family history of breast cancer should be assessed.
- Obtain data on the patient's lifestyle and health practices.
- Ask about the use of hormones, contraceptives, or antidepressants.
- Exposure to radiation, benzene, or asbestos should be determined.
- Collect information on the patient's usual diet including alcohol, coffee, tea, soft drinks, and chocolate intake.
- Record the patient's usual exercise patterns.
- Ask about the type of bra worn during exercise.
- Determine if the patient examines their own breasts and the frequency.
- Ask about the date of the patient's last breast exam by a physician.
- Determine the date of the last mammogram.
Objective Data Collection
- Equipment needed include a centimeter ruler, small pillow, gloves, educational materials on breast self-examination, and a slide for education.
- Ensure privacy and instruct the client to disrobe to the waist and put on a gown.
- Observe the general appearance, symmetry, and contour of the breasts.
- Note any retractions and dimpling.
- Assess the color, size, shape, and texture of the areolas.
- Observe the size and direction of the nipples.
- Palpate the breasts for elasticity and temperature.
- Note any masses regarding their location in centimeters, shape, consistency, mobility, and tenderness.
- Compress the nipple gently between the thumb and index finger to observe for discharge.
- If a mastectomy has occurred, observe the scar site, and examine the remaining breast or axillary tissue for lumps, swelling, or tenderness.
- Inspect the skin of the breasts, areolas, and nipples for lesions or ulcerations.
- Note any signs of inflammation or infection.
- Support the patient's arm with one hand and use the three middle fingers of your other hand to palpate firmly each breast.
- To assess the axillae, move downward against the chest wall from the axillae. Continue down the inner aspect of the upper arm and feel for the posterior nodes.
- Palpate high into the axillae to feel for the anterior axillary nodes.
Nursing Assessment
- Formulate nursing diagnoses including wellness, risk, and actual diagnoses.
- Identify collaborative problems and referrals needs.
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