Chapter 18, Breasts, Axillae, and Regional Lymphatics: Findings for the Breasts and Axillae-Sherpath

Question 1 of 12

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Which finding would the nurse expect when assessing the nipple of a light-skinned woman?

• • The nipple is retracted.The nipple of a light-skinned woman should not be retracted. This indicates an abnormal finding and possible malignancy.
• • The areola is brown before pregnancy.The nipple of a light-skinned woman should be a light color, such as pink, not brown, before pregnancy. This indicates an abnormal finding.
• Correct
  • The areola may be brown during pregnancy.The nipples of a light-skinned woman usually turn brown during pregnancy and may remain dark. This is considered a normal finding.
• • The nipple has slight crusting over the opening.The nipples of nonlactating women should not have crusting over the opening. This is an abnormal finding.

Question 2 of 12

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What change may occur in breast appearance in many postmenopausal women?

• • The nipples become larger and flatter with age.In a postmenopausal woman the nipples will not become larger and flatter. This is not an expected finding.
• • The inframammary ridge decreases in size with age.In a postmenopausal woman, the inframammary ridge will not decrease in size. This is not an expected finding.
• • The breasts are closer to the chest wall and swollen.In a postmenopausal woman, the breasts should not appear closer to the chest wall or swollen. This is not an expected finding.
• Correct
  • The breasts are flattened, elongated, and loosened from the wall of the chestIn a postmenopausal woman, the breasts will appear to be loosened from the chest wall, elongated, and flattened. This is primarily due to the tissue atrophy.

Question 3 of 12

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Which findings would the nurse expect when inspecting the breasts of an adolescent girl?

• • The breast tissue is dense and firm.Breast tissue should be dense and firm in an adolescent girl, but this is a normal finding for palpation, not inspection.
• • The breasts have several lumps.When inspecting the breasts of an adolescent girl, the nurse should not expect to find several lumps. This is an abnormal finding.
• Correct
  • The breast tissue appears firm and tight.When inspecting the breasts of an adolescent girl, the nurse should expect to find that the breast tissue appears to be firm and tight.
• • The breasts have not started to mature yet.When inspecting the breasts of an adolescent girl, the nurse should expect to find that the breasts have started to mature. This is an abnormal finding.
• Correct
  • The left breast is larger than the right breast.When inspecting the breasts of an adolescent girl, the nurse may find that one breast is larger than the other. The breasts may not develop at the same rate.

Question 4 of 12

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When palpating the breasts of a new mother whose milk has just come in, which findings would the nurse expect?

• Correct
  • Firm, dense, and slightly enlarged breastsOn palpation of the breasts of a new mother whose milk has just come in, finding the breasts to be firm, dense, and slightly enlarged is normal.
• • Lack of milk expressionA new mother whose milk just came in should have some milk expressed during palpation. If milk is not coming out, a problem is indicated.
• • A tender lumpy nodule that is hot to the touchOn palpation of the breasts of a new mother whose milk has just come in, finding a lumpy hot nodule could indicate a clogged milk duct.
• • One breast that is significantly smaller than the otherOn palpation of the breasts of a new mother whose milk has just come in, finding that one breast is smaller than the other could indicate that the breast is not producing milk. This is an abnormal finding.

Question 5 of 12

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Which finding is expected on palpation of an older adult woman’s breast?

• • The nipples are elevated slightly.On palpation of the breasts of an older woman, the nipples should not be elevated, but nipple elevation is a finding of inspection, not palpation.
• • The breasts will have a lobular feel.On palpation of the breasts of an older woman, the breast tissue should not have a lobular feel.
• Correct
  • The breasts have a fine, granular feel.On palpation of the breasts of an older woman, the breast tissue should have a fine, granular feel.
• • The inframammary ridge cannot be felt.On palpation of the breasts of an older woman, the inframammary ridge should be felt because it has thickened.

Question 6 of 12

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Which findings would be considered normal on palpation of the breasts of a newborn?

• • The breast tissue is slightly lumpy.On palpation of the breast tissue of a newborn, the breast tissue should not be lumpy. This is not a normal finding.
• • The nipples invert into the breasts.On palpation of the breast tissue of a newborn, the nipples should not invert into the breast. This is not a normal finding.
• Correct
  • Breast tissue is slightly enlarged.On palpation of the breast tissue of a newborn, the breast tissue will be slightly enlarged. This is a normal finding caused by the presence of the mother’s hormones.
• Correct
  • Tissue can be easily palpated behind the nipple.On palpation of the breast tissue of a newborn, the tissue can be easily palpated behind the nipple. This is a normal finding.
• Correct
  • A small amount of clear fluid is discharged from the nipple.On palpation of the breast tissue of a newborn, a small amount of clear fluid may be discharged from the nipple. This is a normal finding. (Some refer to this as “witch’s milk.”)

Question 7 of 12

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Which abnormal assessment findings indicate swelling in the breast tissue when noted during inspection?

• • The skin appears smooth.A smooth appearance in the skin of the breast does not indicate swelling.
• Correct
  • The skin appears thicker.The skin over swollen breast tissue appears thicker due to the presence of fluid.
• • Venous network is not visible.Inability to visualize the venous network of the breast is not an indication of swollen breast tissue.
• Correct
  • There are large pores in the skin.The skin over swollen breast tissue will appear to have large pores.
• Correct
  • Skin markings can be visualized clearly.Skin markings on the swollen breast can be clearly visualized.

Question 8 of 12

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On assessment of the nipples, which finding would be considered abnormal?

• • The nipples are everted.Everted nipples would be considered a normal finding. Most nipples are everted.
• • The nipples have small bumps.Small bumps on the nipples indicate Montgomery tubercles. This is considered a normal finding.
• • The nipples are pink, brown, or black.The color of the nipples ranges from pink to brown to black; this would be considered a normal finding.
• Correct
  • One nipple points in a different direction.Nipples pointing in different directions would indicate an abnormal finding during breast inspection.

Question 9 of 12

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Which inspection findings are considered abnormal on inspection of the breasts of a female patient who has had a right mastectomy?

• Correct
  • RednessRedness is considered an abnormal finding, as it could indicate a return of malignancy.
• Correct
  • SwellingSwelling is considered an abnormal finding, as it could indicate a return of malignancy.
• • Flat scarThe scar should be flat against the skin. This is a normal finding.
• • Warm skinThe skin should be warm. This is a normal finding.
• Correct
  • Scar irritationScar irritation is considered an abnormal finding, as it could indicate a return of malignancy.

Question 10 of 12

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Which finding would the nurse note as abnormal when assessing a female patient’s breast?

• • A lobular feel is present.The tissue should have a lobular feel. This is a normal finding.
• • The breast tissue feels dense and firm.The tissue should feel firm and dense. This is a normal finding.
• Correct
  • A small, nontender nodule is found in the right breast.Detection of a small, nontender nodule in the right breast is abnormal and warrants further investigation.
• • A ridge is felt along the lower edge of the breast.The ridge felt along the lower edge of the breast is the inframammary ridge. This is a normal finding.

Question 11 of 12

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Which assessment finding would the nurse note as abnormal when palpating the axillary lymph nodes in a patient?

• • No discomfort or painWhen palpating the axillary lymph nodes in a patient, the nurse would expect the patient to have no discomfort or pain. This is a normal finding.
• Correct
  • A palpable lymph nodeOn palpation of the axillary lymph nodes, a palpable lymph node is an abnormal finding. It is an indication of malignancy.
• • No palpable nodulesWhen palpating the axillary lymph nodes in a patient, the nurse would not expect to palpate any nodules. The absence of nodules is a normal finding.
• • A deep hollow in the axillary regionWhen palpating the axillary lymph nodes in a patient, the nurse would expect to palpate a deep hollow in the axillary region. This is a normal finding.

Question 12 of 12

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Which finding would the nurse note as abnormal when assessing the breast tissue of a teenage boy?

• • A firm disc of tissueOn assessment of the breast tissue of a teenage boy, a firm disc of tissue is a normal finding.
• • A thin layer of fatty tissueOn assessment of the breast tissue of a teenage boy, a thin layer of fatty tissue is a normal finding.
• Correct
  • Enlarged breast tissueOn assessment of the breast tissue of a teenage boy, enlarged breast tissue is an abnormal finding, indicating gynecomastia.
• • Even amount of breast tissue in both breastsOn assessment of the breast tissue of a teenage boy, the same amount of tissue in each breast is a normal finding.

When inspecting a patient’s areolae, which assessment findings would be considered normal? Round or oval shape and symmetrical
Which assessment finding is considered normal during inspection of a woman’s breasts? One breast is slightly smaller
Which assessment finding is expected when palpating a man’s breast tissue? Feeling a thin layer of fatty tissue over the muscle
Which findings would the nurse expect when palpating a woman’s breast tissue?

1. Dense nature
2. Firmness
3. Elasticity
   Which assessment finding is considered abnormal on inspection of a breastfeeding patient’s
   nipples? Cracked nipples
   On assessment of a patient’s nipples, the nurse notes retraction. Which description best
   describes this abnormal finding? Flattening or pulling back of the nipple
   A mother who is breastfeeding her baby complains of pain and tenderness in the right breast.
   Which finding would be considered abnormal during palpation of the breast tissue? A hot raised nodule is detected
   Which findings would the nurse consider abnormal when palpating the breast tissue of a
   9-month-old infant?
4. Swelling or enlargement
5. Milky white discharge from the nipple