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Breasts and Axillae Test Bank Answers Ch17

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 17 Breasts and Axillae

The nurse is conducting a breast health workshop for a group of women. Which would the nurse include in this workshop when outlining risk factors for breast cancer? 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.

Page Ref: 342

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is reviewing the function of the breasts with a client. Which information should the nurse include? Select all that apply.

1. Release lactating hormones.

2. Mechanism for sexual arousal.

3. Produce milk.

4. Store milk.

5. Contain lymphatic tissue for immunity.

Page Ref: 339

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is preparing to palpate the lymph nodes of a client's breast. Which lymph nodes will the nurse palpate? Select all that apply.

1. Brachial nodes.

2. Subclavicular nodes.

3. Inguinal nodes.

4. Supraclavicular nodes.

5. Internal mammary nodes.

Page Ref: 424

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.4: Outline the techniques for assessment of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting?

1. Symmetry.

2. Hard nodules.

3. Tenderness.

4. Skin consistency.

Page Ref: 347

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.5: Generate the appropriate documentation to describe the assessment of the breasts and axillae.

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

The nurse is preparing to discuss the modifying risk factors for breast cancer with a community group. Which risk factors should the nurse include in the discussion? Select all that apply.

1. Smoking.

2. Physical activity.

3. Alcohol use.

4. Obesity.

5. Diet.

Page Ref: 434

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is asking a client questions regarding lifestyle patterns. Which statement by the client would alert the nurse to possible risk for breast cancer?

1. "I work in a chemical factory."

2. "I drink two glasses of wine each night."

3. "I have smoked two packs of cigarettes daily for four years."

4. "I occasionally have unprotected sexual contact with unknown partners."

Page Ref: 342

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.3: Determine which questions about the breasts and axillae to use for the focused interview.

MNL Learning Outcome: 17.2: Plan questions about the breasts and axillae for the focused interview.

The nurse is discussing breast health with a 65-year-old client. Which screening recommendation should the nurse discuss?

1. Mammograms every 1 year.

2. Mammograms every 2 years.

3. There are no clear recommendations.

4. Recommended screening is based on the client's decision.

Page Ref: 341

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

The nurse is assessing a client and confirms the presence of galactorrhea. Which conclusion by the nurse is the most appropriate?

1. It suggests an endocrine disorder.

2. It may indicate a malignancy.

3. It suggests a breast infection.

4. It is usually indicative of lactation.

Page Ref: 353

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is examining a client with a history of benign breast disease. Which findings does the nurse anticipate when assessing this client's breasts? Select all that apply.

1. Straw-colored discharge from the nipples.

2. Freely movable masses.

3. Hard, fixed nodules.

4. Thickened breast tissue.

5. Masses with well-defined boundaries.

Page Ref: 356

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is teaching a client with benign breast disease about symptom relief. Which topic would the nurse include in this session?

1. Avoiding all fat in the diet.

2. Heat application.

3. Limiting salt intake.

4. Drinking tea instead of coffee.

Page Ref: 356

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Non-Pharmacological Comfort Interventions

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is reviewing the prescriptions for a client experiencing galactorrhea. Which prescription should the nurse understand is associated with galactorrhea?

1. Sertraline.

2. Glucophage.

3. Levothyroxine.

4. Amoxicillin.

Page Ref: 353

Cognitive Level: Analyzing

Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is preparing to review the characteristics of noncyclic mastalgia with a client. Which factors should the nurse discuss with the client? Select all that apply.

1. Often unilateral.

2. Most common in younger women.

3. Results from changes in breast structure.

4. Pain is often described as sharp and burning.

5. Typically disappears after menopause.

Page Ref: 343

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is interviewing a 37-year-old client for breast cancer risks. Which statement by the client indicates an appropriate understanding of the risks associated with breast cancer?

1. "I know my risk for breast cancer increases with age."

2. "A mammogram every three years is my goal."

3. "I will see my healthcare provider every two years for a breast examination."

4. "My family history is negative so I do not need to worry."

Page Ref: 342

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is gathering statistics on breast cancer for a community presentation. Which facts about breast cancer should the nurse include? Select all that apply.

1. Breast cancer is one of the most common cancers in females.

2. Most often diagnosed in White women.

3. Geographical breast health disparities occur based on region.

4. More common in African American women under age 45.

5. White women are more likely to die from breast cancer.

Page Ref: 342

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse performing a breast examination is palpating the tail of Spence. Why is it appropriate to palpate this area of the breast during an examination?

1. It does not contain any lymph nodes.

2. It can show the difference between fibrocystic disease and fibroadenomas.

3. Breast cancer occurs more frequently in this area.

4. Peau d'orange may occur in this area of the breast.

Page Ref: 351

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.4: Outline the techniques for assessment of the breasts and axillae.

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

A menopausal woman comes to the clinic with complaints of thin, watery nipple discharge with blood present. Based on this data, which disorder does the nurse suspect?

1. Mammary duct ectasia.

2. Fibrocystic disease.

3. Breast malignancy.

4. Intraductal papillomas.

Page Ref: 356

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

A client asks the nurse how milk is produced. When responding to the client, which structure will the nurse include as being responsible for milk production?

1. Montgomery's glands.

2. Areola.

3. Acini cells.

4. Mammary ridge.

Page Ref: 338

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

During the breast examination on a client, the nurse palpates a small, subclavicular node on the right side of the client's chest. Which is the priority nursing action at this time?

1. Call the primary care provider.

2. Ask the client if they have a family history of breast cancer.

3. Continue with the exam.

4. Schedule a mammogram for the next available appointment.

Page Ref: 341

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

A client asks the nurse what is the purpose of the Montgomery's glands on the nipple of the breast. Which information should the nurse be prepared to discuss?

1. Secretion of oily secretions.

2. Secretion of milk.

3. Secretion of hormones.

4. Secretion of colostrum.

Page Ref: 338

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is planning to perform a breast examination of a female client. Which techniques does the nurse anticipate documenting? Select all that apply.

1. Inspection.

2. Palpation.

3. Percussion.

4. Auscultation.

5. Client interview.

Page Ref: 342, 347

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 17.5: Generate the appropriate documentation to describe the assessment of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

While the nurse is counseling a client about fibrocystic breast disease, the client asks if having this disorder will lead to cancer. Which response by the nurse is the most appropriate?

1. "There is no direct link between this disease and breast cancer."

2. "You will need to ask the primary healthcare provider that question."

3. "This disease is a form of cancer."

4. "Why are you so worried about this?"

Page Ref: 355

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

An adolescent client with a fibroadenoma asks the nurse what caused the tumor. Which answer should the nurse provide?

1. Inflammation of the breast tissue.

2. Growth of breast tissue.

3. Hormones associated with menstrual cycle.

4. A thickening of the breast tissue.

Page Ref: 356

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

A client asks the nurse why the breast has so many lymph nodes. Which response should the nurse provide?

1. Deliver fluid to the breast tissue and axillae.

2. Drain fluid away from the breast and axillae.

3. Protect the breast tissue from pathogens.

4. Transport hormones to the breast tissue.

Page Ref: 340

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

A parent of a newborn asks the nurse why their son's breast tissue is swollen. Which response should the nurse provide the parent?

1. "I have notified the healthcare provider of this finding."

2. "There must have been some slight trauma to the chest during birth."

3. "The maternal hormones can cause swollen breast tissue."

4. "This is an expected finding in all newborns."

Page Ref: 357

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is providing teaching for a male client taking an estrogenic prescription for a prostate tumor. Which statements made by the client indicates an understanding of the information? Select all that apply.

1. "I may experience an enlargement in breast tissue."

2. "This prescription placed me at risk for breast cancer."

3. "I may experience discomfort in the lymph nodes around my breasts."

4. "I may experience some discharge from my nipples."

5. "I may experience pain and tenderness in my breasts."

Page Ref: 354, 357

Cognitive Level: Analyzing

Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse assessing a client notes that the breasts do not fall freely from the chest. Which should the nurse suspect the finding is associated with?

1. Breast implants.

2. Breast cancer.

3. Pregnancy.

4. Lactation.

Page Ref: 350

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

During a health assessment, a male client voices concern that he is at risk for breast cancer. The nurse is aware that further evaluation of the client's history should focus on predisposing factors that increase the chance for breast cancer in males. The interview should include questions related to which factors? Select all that apply.

1. Previous history of taking testosterone.

2. The client's mother having a history of breast cancer.

3. History of cirrhosis of the liver.

4. History of kidney disease.

5. History of radiation treatment for lung cancer.

Page Ref: 358

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.2: Plan questions about the breasts and axillae for the focused interview.

During a focused assessment, the female client reports breast tenderness, swelling, and lymph node enlargement around the time of her period. Which response by the nurse is the most appropriate?

1. "This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly."

2. "Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider."

3. "As long as you have not detected any lumps, you have nothing to worry about."

4. "Do you have a history of fibrocystic breast disease? These symptoms are usually seen with this disease."

Page Ref: 343

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is preparing an educational session regarding the causes for male gynecomastia. Which items will the nurse include in the session? Select all that apply.

1. Breast cancer.

2. Infants following birth.

3. The onset of puberty.

4. Hormone therapy.

5. Breast infection.

Page Ref: 354

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae

MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.

The nurse is educating a client about breast examination. Which area of the breast should the nurse inform the client that the majority of breast cancer occurs? Select all that apply.

1. Lower inner quadrant.

2. Axillary tail of Spence.

3. Lower outer quadrant.

4. Upper outer quadrant.

5. Areola and the nipple.

Page Ref: 351

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae.

MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.

The nurse is teaching self-breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the nurse why this is necessary. Which response by the nurse is the most appropriate?

1. "It allows any masses to bulge forward to be seen."

2. "This is the only position to detect Paget's disease."

3. "This is the best position to look for skin dimpling."

4. "It is the only way to look for nipple retraction."

Page Ref: 349

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.4: Outline the techniques for assessment of the breasts and axillae.

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

The nurse is performing a focused interview on breast health and is preparing to ask a client a question about internal environment. Which question should the nurse ask?

1. "Have you ever had a mammogram?"

2. "Do you have breast implants?"

3. "Have you been exposed to any environmental toxins?"

4. "Have you experienced any trauma to your breasts?"

Page Ref: 349

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 17.3: Determine which questions about the breasts and axillae to use for the focused interview.

MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.

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DOCX

Chapter Number:

Created Date:

Aug 21, 2025

Chapter Name:

Chapter 17 Breasts and Axillae

Author:

Cynthia Fenske

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Breasts and Axillae Test Bank Answers Ch17

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 17 Breasts and Axillae

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