,NR 304 Exam 2 Health Assessment II | Questions And Answers |
2026/2027 CHAMBERLAIN
1.** The nurse is assessing a client's breasts. Where are the breasts located
anatomically?
A) Between the first and fourth ribs, extending from the sternum to the
posterior axillary line
B) Between the second and sixth ribs, extending from the side of the
sternum to the midaxillary line
C) Between the third and seventh ribs, extending from the clavicle to the
umbilicus
D) Between the fourth and eighth ribs, extending from the sternum to the
anterior axillary line
**Correct Answer:** B) Between the second and sixth ribs, extending from
the side of the sternum to the midaxillary line
**Rationale:** The breasts are located anterior to the pectoralis major and
serratus anterior muscles, between the second and sixth ribs, extending from
the side of the sternum to the midaxillary line. The upper outer quadrant
extends into the axilla as the axillary tail of Spence.
**2.** A nurse is assessing a client's breasts. Which quadrant is the most
common site for breast tumors?
A) Upper inner quadrant
B) Upper outer quadrant
C) Lower inner quadrant
D) Lower outer quadrant
,**Correct Answer:** B) Upper outer quadrant
**Rationale:** The upper outer quadrant is the site of most breast tumors.
This area contains the most glandular tissue and extends into the axillary tail
of Spence.
**3.** The nurse is assessing the axillary lymph nodes. Which of the
following are the four groups of axillary nodes? (Select all that apply.)
A) Central axillary nodes
B) Pectoral (anterior) nodes
C) Subscapular (posterior) nodes
D) Lateral nodes
E) Infraclavicular nodes
**Correct Answers:** A, B, C, D
**Rationale:** The four groups of axillary nodes are: central axillary nodes,
pectoral (anterior) nodes, subscapular (posterior) nodes, and lateral
(brachial) nodes. Infraclavicular nodes (E) are not part of the axillary chain.
**4.** A nurse is assessing a 45-year-old female client's breasts and notes a
peau d'orange appearance of the skin. Which condition does this finding
most strongly suggest?
A) Fibrocystic breast disease
B) Paget's disease
C) Inflammatory breast cancer
D) A benign cyst
, **Correct Answer:** C) Inflammatory breast cancer
**Rationale:** Peau d'orange, meaning "orange peel" skin, is characterized
by edema and dimpling of the breast tissue, often caused by lymphatic
obstruction from an underlying malignancy. Inflammatory breast cancer is a
rare but aggressive form that commonly presents with this classic sign, along
with redness, warmth, and swelling. Fibrocystic changes, Paget's disease,
and benign cysts do not typically cause this characteristic skin change.
**5.** The nurse is assessing a client's breasts. Which structure secretes a
protective lipid material during lactation?
A) Lactiferous ducts
B) Montgomery's glands
C) Alveoli
D) Suspensory ligaments (Cooper's ligaments)
**Correct Answer:** B) Montgomery's glands
**Rationale:** Montgomery's glands are small elevated sebaceous glands in
the areola that secrete a protective lipid material during lactation.
Lactiferous ducts (A) transport milk, alveoli (C) produce milk, and suspensory
ligaments (D) provide support.
**6.** A nurse is providing teaching about breast self-examination (BSE).
Which instruction should the nurse include?
A) "Perform BSE on the first day of your menstrual period."
2026/2027 CHAMBERLAIN
1.** The nurse is assessing a client's breasts. Where are the breasts located
anatomically?
A) Between the first and fourth ribs, extending from the sternum to the
posterior axillary line
B) Between the second and sixth ribs, extending from the side of the
sternum to the midaxillary line
C) Between the third and seventh ribs, extending from the clavicle to the
umbilicus
D) Between the fourth and eighth ribs, extending from the sternum to the
anterior axillary line
**Correct Answer:** B) Between the second and sixth ribs, extending from
the side of the sternum to the midaxillary line
**Rationale:** The breasts are located anterior to the pectoralis major and
serratus anterior muscles, between the second and sixth ribs, extending from
the side of the sternum to the midaxillary line. The upper outer quadrant
extends into the axilla as the axillary tail of Spence.
**2.** A nurse is assessing a client's breasts. Which quadrant is the most
common site for breast tumors?
A) Upper inner quadrant
B) Upper outer quadrant
C) Lower inner quadrant
D) Lower outer quadrant
,**Correct Answer:** B) Upper outer quadrant
**Rationale:** The upper outer quadrant is the site of most breast tumors.
This area contains the most glandular tissue and extends into the axillary tail
of Spence.
**3.** The nurse is assessing the axillary lymph nodes. Which of the
following are the four groups of axillary nodes? (Select all that apply.)
A) Central axillary nodes
B) Pectoral (anterior) nodes
C) Subscapular (posterior) nodes
D) Lateral nodes
E) Infraclavicular nodes
**Correct Answers:** A, B, C, D
**Rationale:** The four groups of axillary nodes are: central axillary nodes,
pectoral (anterior) nodes, subscapular (posterior) nodes, and lateral
(brachial) nodes. Infraclavicular nodes (E) are not part of the axillary chain.
**4.** A nurse is assessing a 45-year-old female client's breasts and notes a
peau d'orange appearance of the skin. Which condition does this finding
most strongly suggest?
A) Fibrocystic breast disease
B) Paget's disease
C) Inflammatory breast cancer
D) A benign cyst
, **Correct Answer:** C) Inflammatory breast cancer
**Rationale:** Peau d'orange, meaning "orange peel" skin, is characterized
by edema and dimpling of the breast tissue, often caused by lymphatic
obstruction from an underlying malignancy. Inflammatory breast cancer is a
rare but aggressive form that commonly presents with this classic sign, along
with redness, warmth, and swelling. Fibrocystic changes, Paget's disease,
and benign cysts do not typically cause this characteristic skin change.
**5.** The nurse is assessing a client's breasts. Which structure secretes a
protective lipid material during lactation?
A) Lactiferous ducts
B) Montgomery's glands
C) Alveoli
D) Suspensory ligaments (Cooper's ligaments)
**Correct Answer:** B) Montgomery's glands
**Rationale:** Montgomery's glands are small elevated sebaceous glands in
the areola that secrete a protective lipid material during lactation.
Lactiferous ducts (A) transport milk, alveoli (C) produce milk, and suspensory
ligaments (D) provide support.
**6.** A nurse is providing teaching about breast self-examination (BSE).
Which instruction should the nurse include?
A) "Perform BSE on the first day of your menstrual period."
