1.
The sebaceous glands on the areola, which enlarge and produce a secretion that protects and lubricates the nipples
Correct Answer
B. Montgomery's glands (tubercles)
Explanation
Montgomery's glands, also known as tubercles, are small sebaceous glands located on the areola. These glands enlarge during pregnancy and produce a secretion that helps protect and lubricate the nipples. This secretion can also have a slight odor that may attract newborns to the breast. Therefore, Montgomery's glands play an important role in breastfeeding and nipple health.
2.
(Tail of Spence) Breast tissue that extends superiolaterally into the axilla
Correct Answer
C. Axillary tail
Explanation
The axillary tail refers to breast tissue that extends into the axilla (armpit). This is a normal anatomical variation and can be felt as a small mass or lump in the armpit area. The axillary tail is important to consider during breast examinations and mammograms as it can be a site for the development of breast cancer.
3.
Glandular tissue in each breast that produce milk
Correct Answer
D. Acini cells
Explanation
Acini cells are the correct answer because they are responsible for producing milk in the glandular tissue of each breast. The acini cells are located in the lobules of the breast and are responsible for synthesizing and secreting milk. These cells are surrounded by myoepithelial cells, which contract and help in the expulsion of milk from the acini into the ducts.
4.
(Coopers ligaments) Ligaments that extend from the connective tissue layer, through the breast, and attach to the fascia underlying the breast
Correct Answer
E. Suspensory ligaments
Explanation
The suspensory ligaments are ligaments that extend from the connective tissue layer, through the breast, and attach to the fascia underlying the breast. These ligaments help to support and maintain the shape of the breast.
5.
"Milk line", which extends from each axilla to the groin
Correct Answer
F. Mammary ridge
Explanation
The correct answer is "mammary ridge". The milk line refers to the embryonic structure that extends from each axilla to the groin, which gives rise to the development of mammary glands. The mammary ridge is a thickening of the ectoderm along this milk line, and it is responsible for the formation of the mammary glands in mammals.
6.
Thick, yellow discharge that may leak from breasts in the month prior to birth in preparation for lactation
Correct Answer
A. Colostrum
Explanation
Colostrum is the correct answer because it is the thick, yellow discharge that may leak from the breasts in the month prior to birth. This discharge is produced in preparation for lactation and contains essential nutrients and antibodies for the newborn baby. Gynecomastia refers to the enlargement of breast tissue in males, peau d'orange is a condition where the skin of the breast resembles the texture of an orange peel, and galactorrhea is the production of breast milk in non-pregnant or non-breastfeeding individuals.
7.
Benign temporary breast enlargement in one or both breasts in males
Correct Answer
B. Gynecomastia
Explanation
Gynecomastia refers to the benign temporary enlargement of one or both breasts in males. This condition is caused by an imbalance of hormones, specifically an increase in estrogen or a decrease in testosterone. It can occur at any age and is commonly seen during puberty or in older men. Gynecomastia is different from other options such as colostrum (the first milk produced by a woman after childbirth), peau d'orange (a condition where the skin of the breast resembles the texture of an orange peel), and galactorrhea (the production of breast milk in a non-lactating individual).
8.
"Orange peel" appearance caused by edema from blocked lymphatic drainage in advanced cancer
Correct Answer
C. Peau d'orange
Explanation
Peau d'orange refers to the "orange peel" appearance of the skin caused by edema, or swelling, from blocked lymphatic drainage in advanced cancer. This condition is characterized by the skin becoming thickened, dimpled, and resembling the texture of an orange peel. It is commonly seen in breast cancer, where the lymphatic drainage is blocked by tumor cells. The other options, colostrum, gynecomastia, and galactorrhea, do not describe the specific appearance caused by blocked lymphatic drainage in advanced cancer.
9.
Lactation not associated with childbearing or breast-feeding
Correct Answer
D. Galactorrhea
Explanation
Galactorrhea is the correct answer because it refers to the spontaneous flow of milk from the breasts, unrelated to childbearing or breast-feeding. Lactation is the production of milk in the breasts, typically associated with pregnancy and breast-feeding. However, galactorrhea can occur in both men and women due to hormonal imbalances or certain medications. Colostrum is the first milk produced by the breasts after childbirth, gynecomastia is the enlargement of breast tissue in males, and peau d'orange refers to the dimpled appearance of the skin, often seen in breast cancer.
10.
A client asks the nurse, "Why do I need to examine my underarms when I perform my breast exam?" Which of the following is the most appropriate response for the nurse to make to this client?
Correct Answer
B. Breast tissue extends into the axilla.
Explanation
Breast tissue extends superiolaterally into the axilla as the axillary tail or Tail of Spence. The axilla is not the hardest area to feel for changes. The upper outer quadrant and Tail of Spence is the more common place for breast cancer to occur in women. It is not easier to detect abnormalities in the Tail of Spence.
Nursing Process Step: Implementation
Cognitive Level: Application
Client Need: Health Promotion and Maintenance
11.
What is the nurse assessing when performing a breast assessment on a client and palpating along the inner aspect of the humerus?
Correct Answer
D. Brachial (lateral axillary) nodes
Explanation
Lymph nodes drain lymph from the breast and axillae and return it to the bloodstream. The lateral axillary (brachial) nodes are included in the breast assessment and are located along the inner aspect of the humerus. The central axillary nodes are located high in the axilla. The subscapular nodes are located along the inner aspect of the latissimus dorsi muscle. The pectoral nodes lie inside the pectoral fold in the axilla.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
12.
A 14-year-old female client is upset because her breast development is not equal. What can the nurse say to this client?
Correct Answer
C. "It is normal for breast tissue development to be unequal during puberty. It will even out as you get older."
Explanation
Growth of the breasts is not steady or symmetrical. Reassure girls that the rate of breast tissue growth depends on changing hormone levels and is uniquely individual. Stating that the breasts look equal to the examiner is not appropriate in this situation. Telling the client not to worry is not an appropriate communication technique. Asking whether the adolescent's mother experienced the same development is not appropriate as it is common and normal for asymmetry to be present during breast development.
Nursing Process Step: Implementation
Cognitive Level: Application
Client Need: Health Promotion and Maintenance
13.
A 65-year-old female client wants to know if she should still continue to perform self breast assessments. The most appropriate response by the nurse is:
Correct Answer
A. "Breast cancer can still develop when you get older."
Explanation
Older clients need reinforcement that, even though they no longer menstruate, they still need to examine their breasts at the same time each month. Breast cancer becomes more common with increasing age; therefore, self breast exams continue to be important in the elderly population. Since breast cancer increases with age, it is important to continue breast self exams. Self exams are recommended even if the woman has annual mammograms. Women need to continue breast self exams after menopause.
Nursing Process Step: Implementation
Cognitive Level: Application
Client Need: Health Promotion and Maintenance
14.
When performing a breast examination, the nurse notes the presence of Montgomerys tubercles, soft tissue bilaterally, palpable infraclavicular lymph nodes, and slight tenderness to deep palpation bilaterally. Which of the findings would the nurse consider a deviation from normal?
Correct Answer
D. Palpable infraclavicular lympH nodes
Explanation
Normal lymph nodes should be nonpalpable. The presence of Montgomery's tubercles, which are tiny sebaceous glands on the areolae, is normal. The tissue of the breast should be soft. Tenderness to deep palpation is not as concerning as palpable lymph nodes in the breast assessment.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
15.
The nurse is planning a focused breast/axillae interview and wants to include a general health question. Which of the following questions would fit these criteria?
Correct Answer
B. "Are you still menstruating?"
Explanation
General health questions for the breast/axillae focused interview include a description of the breasts, changes in the breasts with menstruation, and date of the last menstrual period. Family history of breast cancer is included in questions related to illness or infection. A history of breast trauma is included in questions related to symptoms. Mammogram history is included in questions related to behaviors.
Nursing Process Step: Planning
Cognitive Level: Application
Client Need: Health Promotion and Maintenance
16.
The nurse is preparing to examine the breasts of a male client and plans to do which of the following? Select all that apply.
Correct Answer(s)
A. Position the client in the sitting position for inspection of the breasts.
B. Position the client in the supine position for palpation of the breasts.
C. Palpate the lympH nodes in the axillary region.
Explanation
Position the client in the sitting position for inspection of the breasts.
-The male client should be sitting with arms at his sides during the inspection phase of the assessment.
Position the client in the supine position for palpation of the breasts.
-Palpation of the breast should be done with the male in the supine position.
Palpate the lymph nodes in the axillary region.
-The axillary lymph nodes should be palpated in the male breast exam.
Palpate extensively in the Tail of Spence area since this is where most breast cancers occur in males.
-The nipple area is the most common site for breast cancer in males to occur.
Ask about a family history of testicular cancer since testicular and breast cancer are related conditions.
-There is an increased risk of breast cancer in males with a familial history of breast cancer in primary female relatives.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
17.
A 32-week-pregnant client is upset and thinks she has breast disease because she has a yellowish discharge coming from her breasts. What can the nurse say or do for this client?
Correct Answer
A. "This is normal toward the end of pregnancy and is called colostrum."
Explanation
A thick yellowish discharge called colostrum may be expressed from the breasts in the final weeks of pregnancy. A mammogram is not indicated in this situation since this is a normal finding. The health care provider does not need to be notified since this is a normal finding. The discharge is not indicative of an infection.
Nursing Process Step: Implementation
Cognitive Level: Application
Client Need: Physiological Integrity
18.
The nurse is performing a breast examination. Which of the following reflect abnormal findings during the inspection phase of breast examination?
Correct Answer
D. A woman whose nipples are pointing in different directions
Explanation
Nipples should point in the same direction outward and slightly upward. A change in the direction of point of the nipple is suggestive of an abnormality. It is normal for a woman to have one breast slightly larger than the other unless this is a recent change. The presence of striae (stretch marks) is also considered within normal limits. A bilateral, fine, visible network of veins is considered a normal finding.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
19.
Which of the following positions accentuates the presence of dimpling during the inspection phase of breast assessment?
Correct Answer
C. Sitting with arms raised over the head
Explanation
Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the client's arms raised over the head or the pectoral muscles tightened. Sitting with arms relaxed at the sides gives the examiner a general impression of the breasts. Leaning forward with arms in front of the client demonstrates whether the breasts fall freely from the chest wall. Supine with the arm extended over the head is the position for palpation of the breast.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
20.
During a breast assessment, the nurse notes an inverted right nipple. The nurse knows that this is:
Correct Answer
B. A significant finding if it is recent
Explanation
Recent inversion of a nipple, a change in the direction of the nipple, or retraction of the nipple is suggestive of malignancy. Recent nipple inversion is suggestive of malignancy, but not always indicative of a slow growing tumor. This is not a normal finding in most women nor expected during pregnancy.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
21.
When gathering breast history information on a client, the client states that she has noticed a few drops of clear discharge from her nipples over the past few months. Which of the following actions is most appropriate in this situation?
Correct Answer
C. Ask additional history questions about the discharge and medications she is currently taking.
Explanation
Nipple discharge from medications is usually clear. This discharge is bilateral. Unilateral nipple discharge would be of more concern and perhaps be caused by an intraductal papilloma or cancer. More information needs to be obtained before determining whether to notify the health care provider. The nurse would document the presence of the discharge; however, more information needs to be obtained regarding the discharge. Referral for a mammogram is not indicated at this time.
Nursing Process Step: Implementation
Cognitive Level: Application
Client Need: Physiological Integrity
22.
A 20-year-old client with benign breast disease says she has increased breast pain and tenderness with menses. What should the nurse do in this situation?
Correct Answer
D. Discuss how reducing caffeine and salt intake and wearing a support bra might help.
Explanation
Some studies suggest limiting caffeine, decreasing salt intake, and taking a mild analgesic might help with the breast pain, and wearing a support bra also can decrease discomfort associated with benign breast disease. There is no direct link between benign breast disease and the incidence of cancer. The discomfort associated with this disease is cyclical, occurring in the days prior to menstruation, and does not indicate that a biopsy is needed. The condition occurs during the woman's reproductive years, typically during the 20s. Telling the woman that the condition will soon go away is not correct.
Nursing Process Step: Implementation
Cognitive Level: Application
Client Need: Physiological Integrity
23.
The nurse is palpating the breasts of a 30-year-old nonlactating female. Which of the following would be considered normal for this client?
Correct Answer
A. Smooth, elastic breast tissue
Explanation
The breasts should feel smooth, elastic, and symmetrical. Galactorrhea, lactation not associated with childbearing, occurs most often with endocrine disorders or medications such as antidepressants and antihypertensives. Peau d'orange, orange peel skin, occurs in advanced stages of cancer from blocked lymphatic drainage. Thickening of the skin is abnormal and suggests underlying carcinoma.
Nursing Process Step: Assessment
Cognitive Level: Application
Client Need: Physiological Integrity
24.
The nurse notes the presence of gynecomastia in a 15-year-old client. The nurse knows:
Correct Answer
D. This is a temporary condition in puberty.
Explanation
Gynecomastia (breast enlargement in males) is a normal, temporary condition seen in up to 30% of males at puberty. Gynecomastia is also seen after birth due to circulating maternal hormones and in elderly males. The presence of gynecomastia is considered normal in adolescent males. Men are not at increased risk of developing breast cancer if they have had gynecomastia. This is a normal finding for a male of this age.
Nursing Process Step: Assessment
Cognitive Level: Comprehension
Client Need: Physiological Integrity
25.
Characterized by Lumps, Pain or Tenderness, and Nipple Discharge as a Result of Thickening of the Breast Tissue
Correct Answer
A. Benign Breast Disease
Explanation
Benign breast disease is the correct answer because it encompasses a range of non-cancerous conditions affecting the breast. The symptoms mentioned in the question, such as lumps, pain or tenderness, and nipple discharge, are commonly associated with benign breast diseases. Fibroadenoma, intraductal papilloma, and mammary duct ectasia are specific types of benign breast diseases. Carcinoma of the breast, abnormalities of the male breast, gynecomastia, and carcinoma are not considered benign breast diseases as they involve cancerous or abnormal growths.
26.
-Mobile, Firm, Well-Delineated Lumps
-1-5 cm in diameter
-Freely movable
-Asymptomatic
-Single tumor near the nipple or in the upper outer quadrant
Correct Answer
B. Fibroadenoma
Explanation
Fibroadenoma is the correct answer because it matches all the given characteristics. Fibroadenomas are mobile, well-delineated lumps that are typically 1-5 cm in diameter. They are usually asymptomatic and found as a single tumor near the nipple or in the upper outer quadrant of the breast.
27.
Tiny Growths of Epithelial Cells That Project Into the Lactiferous Ducts
Correct Answer
C. Intraductal Papilloma
Explanation
Intraductal papilloma is the correct answer because it refers to tiny growths of epithelial cells that project into the lactiferous ducts. This condition is a benign breast disease characterized by the development of a small, non-cancerous tumor in the milk ducts. It typically presents with symptoms such as nipple discharge, breast pain, or a palpable lump. Intraductal papilloma is usually diagnosed through imaging tests, such as mammography or ultrasound, and can be treated by surgical excision of the affected duct.
28.
Inflammation of the Lactiferous Ducts Behind the Nipple
Correct Answer
D. Mammary Duct Ectasia
Explanation
Mammary duct ectasia is the most likely explanation for inflammation of the lactiferous ducts behind the nipple. It is a benign breast disease characterized by the dilation and inflammation of the ducts, leading to thickening of the walls and accumulation of fluid. This condition is more common in women who are nearing menopause or have already gone through it. Symptoms may include nipple discharge, nipple retraction, and breast pain. It is important to differentiate mammary duct ectasia from other conditions such as carcinoma of the breast, which is a malignant condition.
29.
Common signs
-Dimpling of the skin
-Deviation of the nipple
-Nipple retraction
-Change in the shape of one breast
-Edema
-Discharge
Correct Answer
E. Carcinoma of the Breast
Explanation
The common signs listed, such as dimpling of the skin, deviation of the nipple, nipple retraction, change in the shape of one breast, edema, and discharge, are all indicative of breast cancer. Carcinoma of the breast refers to the malignant tumor that develops in the breast tissue. Therefore, based on the signs provided, it can be inferred that the correct answer is Carcinoma of the Breast.
30.
Enlargement of the breast tissue in the male. this can occur at birth in response to maternal hormones.
Correct Answer
F. Gynecomastia
Explanation
Gynecomastia refers to the enlargement of breast tissue in males. This condition can occur at birth as a result of exposure to maternal hormones. It is a benign condition and not associated with breast cancer. The other options listed are different types of breast diseases, including fibroadenoma, intraductal papilloma, mammary duct ectasia, and carcinoma of the breast. Gynecomastia is the correct answer because it specifically describes the enlargement of breast tissue in males.
31.
Male breast cancer is rare. less than 1% of all breast cancer ocuurs in men.
Correct Answer
G. Carcinoma
Explanation
Male breast cancer is a rare form of cancer, accounting for less than 1% of all breast cancer cases. The other options listed are benign breast diseases or conditions, such as fibroadenoma, intraductal papilloma, mammary duct ectasia, and gynecomastia. Carcinoma, on the other hand, refers to malignant or cancerous tumors. Therefore, the correct answer is carcinoma, as it is the only option that represents a form of breast cancer.
32.
A circular pigmented field of wrinkled skin containing the nipple
Correct Answer
A. Areola
Explanation
The areola is a circular pigmented field of wrinkled skin that surrounds the nipple. It is a distinguishing feature of the breast and contains numerous Montgomery's glands (tubercles), which secrete a lubricating substance during breastfeeding. The areola also contains axillary tail, acini cells, suspensory ligaments, and is formed during embryonic development by the mammary ridge.