Health Assessment For Nursing Practice 5th Edition by Wilson
Health Assessment For Nursing Practice 5th Edition by Wilson
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Chapter 16: Breasts and Axillae
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | Because deep muscles in that area can mask changes |
| b. | Because some patients avoid this area because of tenderness |
| c. | Because most lymph draining from the breast flows through this area |
| d. | Because supporting ligaments in this area may present as tissue changes |
ANS: C
| Feedback | |
| A | Because deep muscles in that area can mask changes. This answer is incorrect. Palpating the axilla for enlarged lymph nodes is very important. |
| B | Because some patients avoid this area because of tenderness. This answer is incorrect. Palpating the axilla for enlarged lymph nodes is very important. |
| C | Because most lymph draining from the breast flows through this area. More than 75% of lymph drainage from the breast flows outward toward the axillary lymph node. |
| D | Because supporting ligaments in this area may present as tissue changes. This answer is incorrect. Palpating the axilla for enlarged lymph nodes is very important. |
DIF: Cognitive Level: Understand REF: 367| 370| 375
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments
| a. | A woman who had her first child at age 26 |
| b. | A woman who reached menopause at age 58 |
| c. | A woman who breastfed all four of her children |
| d. | A woman who states that she reached menarche at age 14 |
ANS: B
| Feedback | |
| A | A woman who had her first child at age 26 has a low risk. |
| B | A woman who reached menopause at age 58. A long menstrual history (menopause after age 50) increases risk. |
| C | A woman who breastfed all four of her children has a low risk. |
| D | A woman who states that she reached menarche at age 14 has a low risk because the menarche was after 12 years of age. |
DIF: Cognitive Level: Understand REF: 381
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems
| a. | Women in their 30s should have annual clinical breast examinations. |
| b. | Women at high risk of breast cancer should have semiannual mammograms. |
| c. | Women who are postmenopausal require clinical breast examination every 5 years. |
| d. | A screening mammogram is recommended for all women beginning at age 50 years. |
ANS: D
| Feedback | |
| A | Clinical breast examinations are recommended as part of a periodic health examination at least every 3 years for average-risk, asymptomatic women in their 20s and 30s, and annually for asymptomatic women age 40 and older. |
| B | Having semiannual mammograms is more often than necessary. |
| C | Clinical breast examinations are recommended as part of a periodic health examination at least every 3 years for average-risk, asymptomatic women in their 20s and 30s, and annually for asymptomatic women age 40 and older. |
| D | This is the recommendation of the U.S. Preventive Services Task Force. |
DIF: Cognitive Level: Remember REF: 370
TOP: Nursing Process: Intervention
MSC: NCLEX Patient Need Category: Health Promotion and Maintenance: Health Promotion Programs
| a. | Occasional discharge from nipples |
| b. | Supernumerary nipples along the milk line |
| c. | Rash in the axillae associated with change in deodorant |
| d. | Mild breast swelling that fluctuates with the menstrual cycle |
ANS: A
| Feedback | |
| A | Nipple discharge is usually an abnormal finding. A specimen of the discharge should be collected. |
| B | Supernumerary nipples along the milk line are a normal finding in some women. |
| C | A rash in the axillae associated with change in deodorant can be solved by changing deodorant and treating the rash. |
| D | Mild breast swelling that fluctuates with the menstrual cycle is consistent with fibrocystic breast disease. |
DIF: Cognitive Level: Analyze REF: 369| 374| 377
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Need Category: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems
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