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NSG 6020 Health Assessment Final Exam Review/ NSG6020 Health Assessment Final Exam Review

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NSG 6020 Health Assessment Final Exam Review/ NSG6020 Health Assessment Final Exam Review Breast and Lymphatics Statement by the patient would indicate a need for further teaching? A. "The best tim... e to check my breasts is a week before my cycle." B. "I will check my breasts in the shower one week after my cycle." C. "I will exam my breast in a clock-like sequence so that I don't miss any surface area." D. "I will be sure to check my arm pits." A The week before a woman's cycle is not the best time to check for lumps because the breasts become sore and tender and may also be "lumpy" a week prior to the cycle. Answer 2 is incorrect because the week after a woman's cycle is the best time to do the examination, and the shower allows for ease of palpation. Answer 3 in incorrect because a clock-like sequence is the proper way to perform a BSE. Answer 4 is incorrect because under the arms houses lymph nodes and the axillary tail of Spence, which is a common site for breast cancer. A pregnant woman who has breast implants asksthe nurse if she can still breastfeed. What isthe nurse's best response? A. "You should not have any problems breast feeding because your implants do not affect milk production." B. "When the breast implants are inserted they usually affect the milk glands, and breastfeeding is not possible." C. "This would depend on which type of implants were placed and which procedure was used by the surgeon. Check with yoursurgeon to see if your milk production will be affected." C Milk production may vary depending on the procedure. Many women can still breastfeed after breast augmentation. The surgeon would be able to determine this ability. Answers 1 and 2 are incorrect because they may not be true. Only the surgeon can determine if milk production will be affected. Statement by the patient would indicate a need for further teaching? A. "The best time to check my breasts is a week before my cycle." B. "I will check my breasts in the shower one week after my cycle." C. "I will exam my breast in a clock-like sequence so that I don't miss any surface area." D. "I will be sure to check my arm pits." A The week before a woman's cycle is not the best time to check for lumps because the breasts become sore and tender and may also be "lumpy" a week prior to the cycle. Answer 2 is incorrect because the week after a woman's cycle is the best time to do the examination, and the shower allows for ease of palpation. Answer 3 in incorrect because a clock-like sequence is the proper way to perform a BSE. Answer 4 is incorrect because under the arms houses lymph nodes and the axillary tail of Spence, which is a common site for breast cancer. A pregnant woman who has breast implants asksthe nurse if she can still breastfeed. What isthe nurse's best response? A. "You should not have any problems breast feeding because your implants do not affect milk production." B. "When the breast implants are inserted they usually affect the milk glands, and breastfeeding is not possible." C. "This would depend on which type of implants were placed and which procedure was used by the surgeon. Check with yoursurgeon to see if your milk production will be affected." C Milk production may vary depending on the procedure. Many women can still breastfeed after breast augmentation. The surgeon would be able to determine this ability. Answers 1 and 2 are incorrect because they may not be true. Only the surgeon can determine if milk production will be affected. Which of the following statementsistrue regarding the internalstructures of the breast? The breast is: A)mainly muscle, with very little fibrous tissue. B)composed of fibrous, glandular, and adipose tissue. C)composed mostly of milk ducts, known as lactiferous ducts. D)composed of glandular tissue, which supports the breast by attaching to the chest wall. ANS: B The breast is composed of glandular tissue, fibrous tissue (including the suspensory ligaments), and adipose tissue. In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this isthat 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. ANS: B 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. 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 nodes B)Pectoral, lateral, anterior, and sternal nodes C)Central, lateral, pectoral, and subscapular nodes D)Lateral, pectoral, axillary, and suprascapular nodes ANS: C The breast has extensive lymphatic drainage. Four groups of axillary nodes are present: (1) central, (2) pectoral (anterior), (3) subscapular (posterior), and (4) lateral. 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 ANS: B The breast has extensive lymphatic drainage. Most of the lymph, more than 75%, drains into the ipsilateral, or same side, axillary nodes. A 9-year-old girl is in the clinic for a sports physical. 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." ANS: D Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the girl's feelings by using statements like "don't worry" or by sharing personal experiences. The beginning of breast development precedes menarche by about 2 years. [Show More]

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