Nursing Health Assessment Exam 3
1. While inspecting a patient's breasts, the nurse finds that the left breast is
slightly larger than the right with the bilateral presence of Montgomery
glands.
The nurse should:
a. Palpate over the Montgomery glands, checking for drainage.
b. Consider these findings as normal, and proceed with the examination.
c. Ask extensive health history questions regarding the woman's breast
asym-metry.
d. Continue with the examination, and then refer the patient for further eval-
uation of the Montgomery glands.: b. Consider these findings as normal, and
proceed with the examination.
Normal findings of the breast include one breast (most often the left) slightly larger
than the other and the presence of Montgomery glands across the areola.
2. Which of the following statements is true regarding the internal structures
of the breast? The breast is made up of:
a. Primarily muscle with very little fibrous tissue.
b. Fibrous, glandular, and adipose tissues.
c. Primarily milk ducts, known as lactiferous ducts.
d. Glandular tissue, which supports the breast by attaching to the chest wall.:
B. Fibrous, glandular, and adipose tissues.
3. In performing a breast examination, the nurse knows that examining the
upper outer quadrant of the breast is especially important. The reason for this
is that the upper outer quadrant is:
a. The largest quadrant of the breast.
b. The location of most breast tumors.
c. Where most of the suspensory ligaments attach.
d. More prone to injury and calcifications than other locations in the breast.:
B. The location of most breast tumors
The upper outer quadrant is the site of most breast tumors. In the upper outer
quadrant, the nurse should notice the axillary tail of Spence, the cone-shaped breast
tissue that projects up into the axilla, close to the pectoral group of axillary lymph
nodes.
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4. In performing an assessment of a woman's axillary lymph system, the nurse
should assess which of these nodes? a. Central, axillary, lateral, and sternal
b. Pectoral, lateral, anterior, and sternal
c. Central, lateral, pectoral, and subscapular
d. Lateral, pectoral, axillary, and suprascapular: C. Central, lateral, pectoral,
subscapular
5. If a patient reports a recent breast infection, then the nurse should expect
to find ________ node enlargement. a. Nonspecific
b. Ipsilateral axillary
c. Contralateral axillary
d. Inguinal and cervical: B. Ipsilateral axilary
6. A 9-year-old girl is in the clinic for a sport physical examination. After some
initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet,
but I have some friends who do. What if I never get breasts?" The nurse's best
response would be:
a. "Don't worry, you still have plenty of time to develop."
b. "I know just how you feel, I was a late bloomer myself. Just be patient, and
they will grow."
c. "You will probably get your periods before you notice any significant
growth in your breasts."
d. "I understand that it is hard to feel different from your friends. Breasts
usually develop between 8 and 10 years of age.": D.
7. A patient contacts the office and tells the nurse that she is worried about
her 10-year-old daughter having breast cancer. She describes a unilateral
enlargement of the right breast with associated tenderness. She is worried
because the left breast is not enlarged. What would be the nurse's best
response? Tell the mother that:
a. Breast development is usually fairly symmetric and that the daughter
should be examined right away.
b. She should bring in her daughter right away because breast cancer is
fairly common in preadolescent girls.
c. Although an examination of her daughter would rule out a problem, her
breast development is most likely normal.
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d. It is unusual for breasts that are first developing to feel tender because
they haven't developed much fibrous tissue.: C. Although an examination of her
daughter would rule out a problem, her breast development is most likely normal 8.
A 14-year-old girl is anxious about not having reached menarche. When
taking the health history, the nurse should ascertain which of the following?
The age that:
a. The girl began to develop breasts.
b. Her mother developed breasts.
c. She began to develop pubic hair.
d. She began to develop axillary hair.: A. The girl began to develop breasts
Full development from stage 2 to stage 5 takes an average of 3 years, although the
range is 1 to 6 years. Pubic hair develops during this time, and axillary hair appears
2 years after the onset of pubic hair. The beginning of breast development precedes
menarche by approximately 2 years. Menarche occurs in breast development stage
3 or 4, usually just after the peak of the adolescent growth spurt, which occurs
around age 12 years
9. A woman is in the family planning clinic seeking birth control information.
She states that her breasts "change all month long" and that she is worried
that this is unusual. What is the nurse's best response? The nurse should
tell her that:
a. Continual changes in her breasts are unusual. The breasts of
nonpregnant women usually stay pretty much the same all month long.
b. Breast changes in response to stress are very common and that she
should assess her life for stressful events.
c. Because of the changing hormones during the monthly menstrual cycle,
cyclic breast changes are common.
d. Breast changes normally occur only during pregnancy and that a
pregnancy test is needed at this time.: c. Because of the changing hormones
during the monthly menstrual cycle, cyclic breast changes are common.
Breasts of the nonpregnant woman change with the ebb and flow of hormones
during the monthly menstrual cycle. During the 3 to 4 days before menstruation, the
breasts feel full, tight, heavy, and occasionally sore. The breast volume is smallest
on days 4 to 7 of the menstrual cycle.
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10. A woman has just learned that she is pregnant. What are some things the
nurse should teach her about her breasts?
a. She can expect her areolae to become larger and darker in color.
b. Breasts may begin secreting milk after the fourth month of pregnancy.
c. She should inspect her breasts for visible veins and immediately report
these.
d. During pregnancy, breast changes are fairly uncommon; most of the
changes occur after the birth.: A. She can expect her areolae to become larger
and darker in color
The areolae become larger and grow a darker brown as pregnancy progresses, and
the tubercles become more prominent. (The brown color fades after lactation, but
the areolae never return to their original color). A venous pattern is an expected
finding and prominent over the skin surface and does not need to be reported. After
the fourth month of pregnancy, colostrum, a thick, yellow fluid (precursor to milk),
may be expressed from the breasts.
11. The nurse is teaching a pregnant woman about breast milk. Which
statement by the nurse is correct?
a. "Your breast milk is immediately present after the delivery of your baby."
b. "Breast milk is rich in protein and sugars (lactose) but has very little fat."
c. "The colostrum, which is present right after birth, does not contain the
same nutrients as breast milk."
d. "You may notice a thick, yellow fluid expressed from your breasts as early
as the fourth month of pregnancy.": D. You may notice a thick, yellow fluid
expressed from your breasts as early as the fourth month of pregnancy
After the fourth month, colostrum may be expressed. This thick yellow fluid is the
precursor of milk, and it contains the same amount of protein and lactose but
practically no fat. The breasts produce colostrum for the first few days after delivery.
It is rich with antibodies that protect the newborn against infection; therefore,
breastfeeding is important.
12. A 65-year-old patient remarks that she just cannot believe that her breasts
"sag so much." She states it must be from a lack of exercise. What
explanation should the nurse offer her? After menopause:
a. Only women with large breasts experience sagging.
