NSG 6020 Final Exam

NSG 6020 Final Exam Final Breast and Lymphatics 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 asks the nurse if she can still breastfeed. What is the 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 your surgeon 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, NSG 6020 Final Exam 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 asks the nurse if she can still breastfeed. What is the 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 your surgeon 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 statements is true regarding the internal structures 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 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. 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. 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? A)Tell the mother that breast development is usually fairly symmetric and she should be examined right away. B)Tell the mother that she should bring her daughter in right away because breast cancer is fairly common in preadolescent girls. C)Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development. D)Tell the mother that it is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue. ANS: C Occasionally one breast may grow faster than the other, producing a temporary asymmetry. This may cause some distress; reassurance is necessary. Tenderness is common also. A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: A)she began to develop breasts B)her mother developed breasts C)she began to develop pubic hair D)she began to develop axillary hair. ANS: A Full development from stage 2 to stage 5 takes an average of 3 years, although the range is 1.5 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 about 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. See Figure 17-6. 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? A)Tell her that it is unusual. The breasts of nonpregnant females usually stay pretty much the same all month long. B)Tell her that it is very common for breasts to change in response to stress and that she should assess her life for stressful events. C)Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. D)Tell her that breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time. ANS: C 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. 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 report this immediately. D)During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth. ANS: A 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 the original color). A venous pattern is prominent over the skin surface and does not need to be reported as it is an expected finding. After the fourth month, colostrum, a thick, yellow fluid (precursor to milk) may be expressed from the breasts. The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? A)"Your breast milk is present immediately after delivery of the 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 nutrition as breast milk does." D)"You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy." ANS: D 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, so breastfeeding is importat A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her? A)After menopause, only women with large breasts experience sagging. B)After menopause, sagging is usually due to decreased muscle mass within the breast. C)After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. D)After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. ANS: D After menopause, the glandular tissue atrophies and is replaced with connective tissue. The fat envelope atrophies also, beginning in the middle years and becoming marked in the eighth and ninth decades. These changes decrease breast size and elasticity, so the breasts droop and sag, looking flattened and flabby In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? A)Recommend that he make an appointment with his physician for a mammogram. B)Ignore it; it is not unusual for men to have benign breast enlargement. C)Explain that this condition may be the result of hormonal changes and recommend that he see his physician. D)Tell him that gynecomastia in men is usually associated with prostate enlargement and recommend that he be screened thoroughly. ANS: C Gynecomastia may reappear in the aging male and may be due to testosterone deficiency. During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? A)Ask her if her periods have started. B)Assess the girl's weight and body mass index (BMI). C)Ask the girl's mother at what age she started to develop breasts. D)Nothing; this is a normal finding. ANS: B Research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before age 8 years for African-American girls and age 10 years for white girls) and early menarche. The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer? A)African-American B)White C)Asian D)American Indian ANS: A The incidence of breast cancer varies with different cultural groups. White women have a higher incidence of breast cancer than African-American women starting at age 45 years; but African-American women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer (American Cancer Society, ). The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in African-American women in the United States? A)Breast cancer is not a threat to African-American women. B)African-American women have a lower incidence of regional or distant breast cancer than white women. C)African-American women are more likely to die of breast cancer at any age. D)Breast cancer incidence in African-American women is higher than that of white women after age 45. ANS: C African-American women have a higher incidence of breast cancer before age 45 years than white women, and are more likely to die of their disease. In addition, African-American women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. This racial difference in mortality rates may be related to insufficient use of screening measures and lack of access to health care. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: A)"Don't worry about the pain; breast cancer is not painful." B)"I would like some more information about the pain in your left breast." C)"Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." D)"Breast pain is almost always the result of benign breast disease." ANS: B Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the patient's pain rather than make statements that ignore the patient's concerns. During a history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? A)Contact the physician immediately to report the discharge. B)Ask her if she is possibly pregnant. C)Ask her some additional questions about the medications she is taking. D)Immediately obtain a sample for culture and sensitivity testing. ANS: C The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be expressed after the fourth month of pregnancy. During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine? A)Is the rash raised and red? B)Does it appear to be cyclic? C)Where did it first appear—on the nipple, the areola, or the surrounding skin? D)What was she doing when she first noticed the rash, and do her actions make it worse? ANS: C It is important for the nurse to determine where the rash first appeared. Paget's disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at nipple unless it results from breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple. See Table 17-6. A patient is newly diagnosed with benign breast disease. The nurse recognizes that which statement about benign breast disease is true? The presence of benign breast disease: A)makes it harder to examine the breasts. B)frequently turns into cancer in a woman's later years. C)is easily reduced with hormone replacement therapy. D)is usually diagnosed before a woman reaches childbearing age. ANS: A The presence of benign breast disease (formerly fibrocystic breast disease) makes it harder to examine the breasts; the general lumpiness of the breast conceals a new lump. The other statements are not true. During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: A)BSEs may detect lumps that appear between mammograms. B)breast self-examination is unnecessary until the age of 50 years. C)she is correct, mammography is a good replacement for breast self-examination. D)she doesn't need to perform breast self-examination as long as a physician checks her breasts yearly. ANS: A The monthly practice of breast self-examination, along with clinical breast examination and mammograms are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms. During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding? A)"Breastfed babies tend to be more colicky." B)"Breastfeeding provides the perfect food and antibodies for your baby." C)"Breastfed babies eat more often than infants on formula." D)"Breastfeeding is second nature and every woman can do it." ANS: B Exclusively breastfeeding for 6 months provides the perfect food and antibodies for the baby, decreases the risk of ear infections, promotes bonding, and provides relaxation The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? A)37 year old who is slightly overweight B)42 year old who has had ovarian cancer C)45 year old who has never been pregnant D)65 year old whose mother had breast cancer ANS: D Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or daughter) and being older than 50 years. Refer to Table 17- 2 for other risk factors. During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? A)Breasts should always be symmetric. B)This finding is probably due to breastfeeding and is nothing to worry about. C)This finding is not unusual, but the nurse should verify that this change is not new. D)This finding is very unusual and means she may have an inflammation or growth. ANS: C The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth. The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? A)Woman whose nipples are in different planes (deviated) B)Woman whose left breast is slightly larger than her right C)Nonpregnant woman whose skin is marked with linear striae D)Pregnant woman whose breasts have a fine blue network of veins visible under the skin ANS: A The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings. See Table 17-3. During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? A)Normal nipple inversion is usually bilateral. B)A unilateral inversion of a nipple is always a serious sign. C)It should be determined whether the inversion is a recent change. D)Nipple inversion is not significant unless accompanied by an underlying palpable mass. ANS: C The nurse should distinguish a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out (i.e., it is not fixed). Recent nipple retraction signifies acquired disease. See Table 17-3. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: A)bend over and touch her toes. B)lie down on her left side and notice any retraction. C)shift from a supine position to a standing position; notice any lag or retraction. D)slowly lift her arms above her head and note any retraction or lag in movement. ANS: D Direct the woman to change position while checking the breasts for skin retraction signs. First ask her to lift her arms slowly over her head. Both breasts should move up symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. The nurse should notice if there is a lag in movement of one breast. The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? A)Supine with arms raised over her head B)Sitting with arms relaxed at the sides C)Supine with arms relaxed at the sides D)Sitting with arms flexed and fingertips touching shoulders ANS: A The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and displace it medially. Any significant lumps will then feel more distinct Which of these clinical situations would the nurse consider to be outside normal limits? A)A patient has had one pregnancy. She states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and sag slightly. B)A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. C)A patient has never been pregnant. She reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. D)A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples. ANS: D In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels softer and looser. If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, discharge is abnormal. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breasts. A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: A)palpate the lump first. B)palpate the unaffected breast first. C)avoid palpating the lump because it could be a cyst, which might rupture. D)palpate the breast with the lump first but plan to palpate the axilla last. ANS: B If the woman mentions a breast lump she has discovered herself, the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual. The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: A)the shape of the lump. B)the lump's consistency. C)the size of the lump. D)whether the lump is solitary or multiple. ANS: C If the nurse feels a lump or mass, he or she should note these characteristics: (1) location, (2) size—judge in centimeters in three dimensions: width × length × thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy. The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? A)The best time to perform BSE is in the middle of the menstrual cycle. B)The woman needs to do BSE only bimonthly unless she has fibrocystic breast tissue. C)The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. D)If she suspects that she is pregnant, the woman should not perform a BSE until her baby is born. ANS: C The nurse should help each woman establish a regular schedule of self-care. The best time to conduct breast self-examination is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. Advise the pregnant or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month, for example, her birth date or the day the rent is due. The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? A)"BSE is more important than ever for you because you have never had any children." B)"BSE is so important because one out of nine women will develop breast cancer in her lifetime." C)"BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations." D)"BSE will save your life because you are likely to find a cancerous lump between mammograms." ANS: C The nurse should stress that a regular monthly self-examination will familiarize her with her own breasts and their normal variations. This is a positive step that will reassure her of her healthy state. While teaching, the nurse should focus on the positive aspects of breast self-examination and should avoid citing frightening mortality statistics about breast cancer. This may generate excessive fear and denial that actually obstructs a woman's self-care action. A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: A)"This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." B)"This is a normal change that occurs as women get older. It is due to the increased levels of progesterone during the aging process." C)"Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." D)"Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help to prevent the changes in elasticity and size." ANS: C The hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more pendulous, flattened, and sagging. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is: A)"Because of the change in consistency of the lump, it should be further evaluated by a physician." B)"The changes could be related to your menstrual cycles. Keep track of changes in the mass each month." C)"This is probably nothing to worry about because it has been present for years and was determined to be noncancerous at that time." D)"Because you are experiencing no pain and the size has not changed, continue to monitor the lump and return to the clinic in 3 months." ANS: A A lump that has been present for years and is not exhibiting changes may not be serious but still should be explored. Any recent change or new lump should be evaluated. The other responses are not correct. During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate? A)"The best time to examine your breasts is during ovulation." B)"Examine your breasts every month on the same day of the month." C)"Examine your breasts shortly after your menstrual period each month." D)"The best time to examine your breasts is immediately before menstruation." ANS: C The best time to conduct breast self-examination is shortly after the menstrual period when the breasts are the smallest and least congested. The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is: A)the same day every month. B)daily, during the shower or bath. C)1 week after her menstrual period. D)every year with her annual gynecologic examination. ANS: A Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform breast self-examination on a monthly basis. Choosing the same day of the month is a helpful reminder to perform breast self-examination. While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should: A)palpate over the Montgomery's glands, checking for drainage. B)consider these normal findings and proceed with the examination. C)ask extensive history questions regarding the woman's breast asymmetry. D) continue with examination and then refer the patient for further evaluation of the Montgomery's glands. ANS: B Normal findings of the breast include one breast (most often the left) slightly larger than the other and the presence of Montgomery's glands across the areola. During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? A)It is a normal variation and not a significant finding. B)It is a significant finding and needs further investigation. C)It also contains glandular tissue and may leak milk during pregnancy and lactation. D)The patient is correct—it is actually a mole that happens to be located under the breast. ANS: A A supernumerary nipple looks like a mole, but close examination reveals a tiny nipple and areola. It is not a significant finding. While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: A)dimpling. B)retraction. C)peau d'orange. D)benign breast disease. ANS: C This condition is known as peau d'orange. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel look, and this condition suggests cancer. When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: A)continue to nurse on both sides to encourage milk flow. B)discontinue nursing immediately to allow for healing. C)temporarily discontinue nursing on affected breast and manually express milk and discard it. D)temporarily discontinue nursing on affected breast but can manually express milk and give it to the baby. ANS: C With a breast abscess, the patient must temporarily discontinue nursing on the affected breast, manually express the milk, and discard it. Nursing can continue on the unaffected side. A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 101° F. She has also had symptoms of the flu, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? A)Mastitis B)Paget's disease C)Plugged milk duct D)Mammary duct ectasia ANS: A The symptoms describe mastitis, which stems from infection or stasis caused by a plugged duct. A plugged duct does not have infection present. (See Table 17-7.) Refer to Table 17-6 for descriptions of Paget's disease and mammary duct ectasia. During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." This finding suggests: A)dimpling. B)a retracted nipple. C)nipple inversion. D)deviation in nipple pointing. ANS: B The retracted nipple looks flatter and broader, like an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts. The nurse should not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixed. A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true? A)Breast masses in men are difficult to detect because of minimal breast tissue. B)Breast cancer in men rarely spreads to the lymph nodes. C)One percent of all breast cancer occurs in men. D)Most breast masses in men are diagnosed as gynecomastia. ANS: C One percent of all breast cancer occurs in men. Early spread to axillary lymph nodes occurs due to minimal breast tissue. The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse keeps in mind that characteristics of a cancerous mass include which of the following? Select all that apply. A)Nontender mass B)Dull, heavy pain on palpation C)Rubbery texture and mobile D)Hard, dense, and immobile E)Regular border F)Irregular, poorly delineated border ANS: A, D, F Cancerous breast masses are solitary, unilateral, nontender, masses. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They are often painless, although the person may have pain. They are most common in upper outer quadrant. A dull, heavy pain on palpation and a mass with a rubbery texture and a regular border are characteristics of benign breast disease. The nurse is examining a 62-year-old man and notes that he has gynecomastia bilaterally. The nurse should explore his history for which related conditions? Select all that apply. A)Obesity B)Malnutrition C)Hyperthyroidism D)Type 2 diabetes mellitus E)Liver disease F)History of alcohol abuse ANS: A, C, E, F Gynecomastia occurs with obesity, Cushing's syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs: alcohol and marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole, isoniazid), digoxin, ACE inhibitors, diazepam, and tricyclic antidepressants. Which of the following statements is true regarding the internal structures of the breast? The breast is made up of: Fibrous, glandular, and adipose tissues. Clinical breast exam should be performed every - 3 years - GU WOMEN MENORRHAGIA - INREASED AMOUNT OF BLEEDING METORRHAGIA - BLEEDNG BETWEEN PERIODS CERVICAL CANCER SCREENING WITH PAP SHOULD BE DONE EVERY - 3 YEARS Normal ovary size - 2-3CM What is the confirmatory test for HIV? A. ELISA B. Western Blot C. HIV polymerease chain reaction test D. HIV antibody B. Remember that the Western Blot is the confirmatory test for HIV but ELISA is the initial test. If this test is positive then you confirm with the Western Blot. What medication would a patient with HIV be taking everyday for the prevention of pneumocystis carinii pneumonia (pneumocystis jirovecci)? A. Bactrim B. Penicillin C. Doxycyline D. Erythromcycin - A. Bactrim must be taken daily for the prevention of pneumocytis carinii pneumonia. A patient comes into your office complaining of night sweats, weight loss, and fever. You want to test for: A. HIV B. Syphilis C. pneumonia D. chancroid Remember early HIV looks like the flu. How long does it take a patient with HIV to serconvert? A. 6 months to 1 year B. 3 months to 1 year C. 3 weeks to 6 months D. Over one year C. 3 weeks to 6 months - that is why everyone that has had a needle stick will have an initial test then the person will come back in 6 months to retest. What is a normal T-cell (CD4) count? A. 800 B. 400 C. 200 D. None - A. 800 In a patient with HIV if the viral load is high and the CD4 is low you know: A. That they are stable B. That they are severely immunocomprimised C. There immune response is high. - B. These patients have no immunity to fight infection and the virus is running rampant. Chancroid is a: A. Gram positive organism B. Gram negative bacillus C. Co-factor for HIV transmission D. Both B and C - B. Gram negative bacillus (hemophylus ducreyi). High rate of HIV identified among individuals with chancroid. Estimated 10% of patients are also infected with syphilis and HIV. The degree to which those who have a disease screen/test positive is known as: A. Specificity B. Sensitivity - B. Sensitivity: Think how many people are positive. Don't get tricked. This has nothing to do with how many people might be negative. If a patient complains of pain upon urination and does not have a urinary tract infection you suspect: A. Chlamydia B. Syphilus C. PID D. Trichimoniasis - A. Chlamydia: Remember the two sexually transmitted diseases that cause pain upon urination (dysuria) are chlamydia and gonorrhea. Patients who are diagnosed with gonorrhea are also treated for following because of high rates of coinfection: A. Mycoplasma pneumoniae B. Chlamydia trachomatis C. Syphilis D. Pelvic inflammatory disease - B. Chlamydia ( question 16 in Leik) Human papilloma virus (HPV) infection of the larynx has been associated with: A. Laryngeal cancer B. Esophageal stricture C. Cervical cancer D. Metaplasia of squamous cells - A. Laryngeal cancer (page 23) The pap smear result on a 20 year old sexually active student who uses condoms inconsistently show a large amount of inflammation. Which of the following is the best follow-up. A. The NP needs to do cervical cultures to verify the presence of gonorrhea B. Treat the patient with metronidazole vaginal cream over the phone C. Call the patient and tell her she needs a repeat pap smear in 6 months. D. Advise her to use a betadine douche at H (half strength) for three days. - C. A- Gonorrhea can cause cervicitis in women Fitz Hugh Curtis Syndrome is associated with which of the following infections: A. Syphilis B. Chlamydia trachomatis C. Herpes gentitalis D. Lymhogranuloma venereum - B. Chlamydia trachomatis: Fitz Hugh Curtis syndrome consists of persistent right upper quadrant abdominal pain, perihepatitis and genital tract infection. Neisseria gonorrheoeae and chlamydia trachomatis have been identified as the causative agents. A 13 year old adolescent who is not sexually active is brought in by her mother for an immunization update and physical examination. According to the mother her daughter had two doses of hepatitis 1 year ago. All of the following are indicated for this visit except: A. Hapatitis B Vaccine B. Tetanus vaccine C. Screen for depression D. HIV test - D. HIV test. The question does not tell you that the patient has any risk factors for HIV. The ELISA and Western Blot tests are both used to test for the HIV virus. Which of the following statements is correct. A. They are both tests to detect viral RNA B. A positive ELISA screening does not mean the person has HIV infection C. They are both tests used to detect for antibodies against HIV virus. D. They are both the best diagnostic tests for HIV - B. A positive ELISA screening does not mean the person has HIV infection. The ELISA test is always followed by Western blot test to confirm diagnosis. All of the following are infections affecting the vagina or labia except: A. Bacterial Vaginosis B. Candidiasis C. Trichomoniasis D. Chlamydia Trachomatis - D. Chlamydia Trachomatis: Initially infects the cervix and urethra. Signs of infection include vaginal discharge or a burning sensation with urination. The KOH prep (potassium hydroxide) will help you diagnose all of the following conditions except: A. Tinea infections B. Candida albicans infections of the skin C. Bacterial vaginosis D. Atypical bacterial infections - D. Atypical bacterial infections: A KOH test is done to determine whether a fungus is causing the skin infection. Samples from an infected area are treated with KOH which disolves skin cells a nd leaves behind fungus cells that can be seen on a microscope. It is used to diagnose thrush, tinea vesicolor, ringworm, and bacterial vaginosis. KOH potassium hydroxide skin scraping will reveal - hyphae Trichomoniasis characteristics of vaginal discharge - foul, frothy, grayish, strawberry spots, motile porotozoa Bacterial vaginosis characteristics - fishy, white-yellow, creamy, clue cells and whiff test on wet prep Chlamydia characteristics/gonorrhea - yellowish, no odor, purulent discharge, numerous white cells on wet prep All of the following are reportable diseases except: A. Lyme disease B. Gonorrhea C. Nongonococcal urethritis D. Syphilis - C. Nongonococcal urethritis A 20 year old woman who is sexually active complains of copious milk like vaginal discharge. On microscopy the slide reveals a large number of mature squamous epithelial cells. The vaginal pH is 5.o. There are very few leukocytes and no red blood cells seen on the wet smear. Which of the following is most likely. A. Atrophic vaginits B. Bacterial Vaginosis C. Trichomoniasis D. This is a normal finding - B. Diagnosis of BV includes 3 of 4 Amsel criteria (1) white, thick adherent discharge, (2) pH more than 4.5, (3) positive whiff test, (4) clue cells greater than 20% on wet mount (epithelial cells dotted with large numbers of bacteria that obscure cell borders), plus (5) Gram stain. All of the following are clinical findings associated with syphilis except: A. Condyloma lata B. Condyloma acuminata C. Painless chancre D. Rashes on the palms of the hands and the soles of the feet - B. Condyloma acuminata refers to an epidermal manifestation attributed to epidermotropic huan papilloma virus (HPV) The differential diagnosis for genital ulcerations includes all of the following except: A. Syphilis B. Genital herpes C. Chancroid D. Molluscum contagiosum - D. Molluscum contagiosum is a viral skin infection. appears on the face, neck armpits, arms, and hands. Other common places include the genitals, abdomen, and inner thigh. They often begin a small firm dome shaped growths, the surface feels smooth, waxy, or pearly, are flesh colored or pink, have a dimple in the center, may be filled with a waxy or cheesy substance, and are painless. scratching or pricking can spread the virus,. Which type of hepatitis infection is more likely to result in cirrhosis of the liver and the risk of developing heaptocellular carcinoma. A. Hepatitis A virus B. Hepatitis B Virus C. Hepatitis C virus D. Both B and C - D. Of the primary hepatitis viruses only B and C are associated with hepatocellular cancer. A 19 year old male has recently been diagnosed with acute hepatitis B. He is sexually active and is monogamous and reports using condoms inconsistently. Which of the following is recommended for his male sexual partner, who was also recently tested for hepatitis with the following result HBsAG (-); anti-HBs (-); anti-HVC (-); anti HAV (+). A. Hepatitis B Vaccination B. Hepatitis B immuno globulin C. Hepatitis B vaccination and hepatitis immune globulin D. No vaccination is needed at this time. - C. Hepatitis B surface antigen (HBsAg) is a marker for infectivity. If positive it indicates either an acute or chronic hepatitis B infection. Antibody to hepatitis surface antigen (anti-HBs) is a marker of immunity. Antibody to hapatitis B core antigen (anti-HBc) is a marker of acute, chronic, or resolved HBV infection. It may be used in prevaccination testing to determine previous exposure to HBV. Interpretation of the hepatitis B panel for test results: A negative HBsAg and a negative anti-HBc and a negative anti-HBs indicates the patient is susceptible - not immune has not been infected and is still at risk for future infection - need vaccination. Interpretation of the hepatitis C anti HCV screening test that is negative indicates that the patient is not infected. Which of the following is recommended for the treatment of a patient with bacterial vaginosis? A. Azithromycin (Zithromax) B. Doxycyline (Dynapin) C. Ceftriaxone (Rocephin) D. Metronidazole (Flagyl) - D. Treatment for BV is flagyl either orally or vaginally or treatment with clindamycin (cleocin) either orally or vaginally. Treatment for the partner is not recommended by the CDC, since there is no decrease recurrences with partner treatment and no effect on cure rates. All of the following sexually transmitted diseases can become disseminated if not treated except: A. Neissieria gonorrhoeae B. Treponema pallidum C. HIV D. Chlamydia Trahomatis - D. The key to answering this question is to understand the meaning behind disseminated - think wide spread or systemic. Although chlamydia seems like an obvious candidate since it can ascend to the uterus and affect a variety of sites including the eyes and the rectum, the specific type of chlamydia that causes genital infections is not generally thought to cause systemic infection. The predominant infections are urethritis, cervicitis, and proctititis, but chlamydia infection can spread locally to the bartholin glands, endosapinges, or epididymis. Up to 40% of untreated chlamydial cervicitis cases will ascend into the upper genital tract where considerable tubal damage can occur with very few symptoms. A homeless middle aged male complains of migratory arthritis and dysuria. Currently, his right knee is swollen and painful. On examination, green colored purulent discharge is noted. Which of the following do you most likely suspect? A. Gonorrhea B. Chlamydia C. Nongonococcal urethritis D. Acute epididymitis - A. Symptoms of gonorrhea usually appear 3-5 days after the infection however in men symptoms may take up to one month to appear. Early symptoms include dysuria, increased urination, frequency, urgency, white/yellow/or green penile drainage, red or edematous penile urethra, and tender and swollen testes. If the infection spreads systemically fever, rash, and arthritis like symptoms may occur. Which of the following methods is used to diagnose gonorrheal proctitis? A. Serum chlamydia titer B. Gen-Probe C. Thayer Martin culture D. PRP (rapid plasma reagent) and VDRL (venereal disease research lab test) - C. Thayer martin selective agar is an enriched medium for the selective isolation of Neisseria species obtained by cervical culture. A Gram stain of the discharge smear can also be used and shows gram negative diplococci and WBC A 34 year old female is diagnosed with pelvic inflammatory disease. The cervical gen probe result is positive for Neisseria gonorrhoeae and negative for chlamydia trachomatis. All of the following treatments are true regarding the management of this patient except: A. This patient should be treated for chlamydia even though the gen-probe for chlamydia is negative B. Ceftriaxone 250 mg IM and doxycyline 100 mg po BID x 14 days are appropriate treatment for this patient? C. Advise the patient to return to the clinic for repeat pelvic examination in 48 hours D. Repeat Gen-Probe test for chlamydia to ensure that the previous test was not a false negative result - D. Repeating the Gen-probe test for chlamydia is not recommended. The 2010 CDC STD treatment guidelines for pelvic inflammatory disease state: PID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract. Treatment should be initiated as soon as the presumptive diagnosis has been made, because prevention of long term sequelae is dependent on early administration of appropriate antibiotics. All regimens used to treat PID sould also be effective against N. gonorrhoeae and C. trachomatis because negative endocerivcal screening for these organisms does not rule out upper reproductive tract infection. Out patient oral therapy can be considered for women with mild to moderately severe acute PID because the clinical outcomes among women treated with oral therapy are similar o those treated with perenteral therapy. RECOMMENDED REGIMEN: Ceftriaxone 250 mg I.M. in a single dose coupled with doxycylcine 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice daily for 14 days. A 25 year old woman comes into your office complaining of dysuria, pruritis, and purulent vaginal dischage. Pelvic examination reveals a cervix with punctate superficial petechiae (strawberry cervix) and irritated reddened vulvar area, with frothy discharge. Microscopic examination of the discharge reveals unicellular organisms. The correct pharmacological treatment for this condition is: A. Oral metronidazole (Flagyl) B. Ceftriaxone sodium (Rocephin) injection C. Doxycycline hyclate (vibramycin) D. Clotrimazole (Gyne-Lotrimin) cream or suppositories - A. A single dose of metronidazole is effective in the majority of cases of trichomonas infections. The strawberry cervix is considered to be selectively associated with Trichomonas. The etiology is the parastitic protozoan flagellate, T. vaginalis. Symptoms include: fouls smelling vaginal discharge (often fishy), burning and soreness of the vulva, perineum, and thighs, dyspareunia and dysuria. Wet prep microscopic examination should reveal highly motile cells, slightly larger than leukocytes, smaller than epithelial cells. Prophylaxis for pneumocystis carinii pneumonia includes all of the following drugs except: A. Trimethoprim-sulfamethoxazole (Bactrim) B. Dapsone C. Aerosolized pentamidine D. Nedocromil sodium Tilade - D. Nedocromil sodium is a mast cell stabilizer used for the treatment of moderate inflammation of the bronchial tubes and other allergy symptoms. Pneumocystis pneumonia is the most common opportunitic infection in people with HIV. Drugs used to treat PCP include bactrim (first line to treat pnumocystis pneumonia), dapson (antibiotic traditionally used to treat leprosy), pentamidine (antimicrobial used to prevent pneumoystis pneumonia), and atovaquone (naphthoquinones used to treat pneumoystis pneumonia, toxoplasmosis, malaria, and babesia). Which of the following is recommended for treatment by the CDC for a case of uncomplicated gonorrheal and chlamydia infection? A. Metronidazole 250 mg po three times daily for seven days B. Valacylcovir 500 mg po bid for 10 days C. Azithromycin 1 g orally or Doxyclycline 100 mg twice daily for seven days D. One dose of oral Fluconazole 150 mg - C. Azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days is based on the CDC 2010 guidelines for treatment. A patient diagnosed with bacterial vaginosis should be advised that her sexual partner be treated with: A. Ceftriazone (Rocephin) 250 mg with doxycycline 100 mg po bid x 14 days B. Flagyl 500 mg BID x 7 days with 1 dose of azithromycin C. Her partner does not need to be treated D. Lotrimin cream to the penis twice daily for 14 days - C. The usual medical regimen for treatment is the antibiotic flagyl 400 mg twice daily every 12 hours for seven days. Treatment of sexual partners is not warranted. A 38 year old active Asian woman with a history of infertility treatment and severe endometriosis complains to the nurse practitioner in the emergency department of right sided pelvic pain that is steadily getting worse. She also reports small amounts of yellow vaginal discharge on her underwear for the last week. The patient reports expecting her period which has not appeared in the last two months. Which of the following should be performed initially? A. Follicle stimulating hormone and culture and sensitivity testing for vaginal discharge B. Serum quantitative pregnancy test and quantitative cervical Gen-Probe testing C. Pelvic ultrasound and serum quantitative pregnancy test D. Microscopy of vaginal discharge and complete blood count with white cell differential? - C. The most critical step in beginning the workup is to have a high clinical suspicion for ectopic pregnancy (in any woman of childbearing years). Bedside pelvic sonography testing is the imaging test of choice to investigate early pregnancy. Patients with indeterminite ultrasound findings should have a beta-hCG level drawn and should be followed up closely with gynecology to monitor serial beta hcg levels and ultrasonography. Which of the following is the most important differential diagnosis to consider in a 38 year old sexually active Asian woman with a history of infertility treatment and severe endometrosis with right sided pelvic pain that is steadily getting worse and small amounts of yellow colored discharge? A. Tubal ectopic pregnancy and pelvic inflammatory disease B. Mucopurulent cervicitis and tubal ectopic pregnancy C. Human papilloma virus infection of the cervix and pelvic inflammatory disease D. Ovarian cysts and severe endometriosis - A. Her positive physical findings of left adnexal tenderness and discharge suggest an ectopic pregnancy versus pelvic inflammatory disease. Amenorrhea should be treated as a pregnancy until proven otherwise. Vaginal candidiasis is best diagnosed in the primary care arena by the following method: A. Microscopy B. Tzanck smear C. KOH smear whiff test D. Clinical findings only - C. Generally wet preps use 1 to 2 slides to evaluate candida. under a microscope observe for presence and number of wbc's, trichomonads, candidal hphea, or clue cells. Yeast and hyphae may also be present on a wet prep. KOH prep is made by adding a drop of saline suspension of vaginal discharge to a drop of KOH solution. The KOH lyses epithelial cells in 5 to 15 minutes and allows easier visualization of candidal hyphae. *Tzanck test is scraping of an ulcer base to look for tazanck cells, sometimes also called the chickenpox skin test and the herpes skin test. For which diagnosis is the consideration of whether the patient has a bubo necessary. A. Chancroid B. Syphilis C. Genital herpes D. Gonorrhea - A. Remember a Bubo is a swollen lymph node in the genital area often seen with chancroid. A 21 year old Latino male comes into your office presenting with a sore on his penis x2 weeks. On exam, you note an indurated chancre that is painless, along with mild regional lymphadenopathy. Based on your diagnosis, which of the following is your most appropriate order? A. Ceftriaxone B. PCN G C. Azithromycin D. Acylcolovir - B. PCN the nurse practitioner knows that asymptomatic shedding should be considered with which STD/STI? A. Syphilis B. Chlamydia C. HSV-2 D. Gonorrhea - C. HSV-2 In teaching a patient about seroconversion with HIV the nurse practitioner knows: A. Most patients seroconvert within 3-4 weeks of exposure B. Once seroconversion occurs the diagnosis of AIDS is usually made and medication is started in most patients C. Enough antigens have built up in the blood by 6 months to usually detect a virus D. Once seroconversion occurs, the patient may or may not show symptoms. - D All of these are considered part of HIV/AIDS except: A. Fatigue/vague abdominal pain B. Weight loss C. Night Sweats D. Fever - A. Fatigue/vague abdominal pain The pap smear result on a 20 year old sexually active student who uses condoms inconsistently shows a large amount of inflammation. Which of the following is the best follow-up? A. The NP needs to do cervical cultures to verify the presence of gonorrhea B. Treat the patient with metronidazole vaginal cream C. Call the patient and tell her she needs a repeat pap smear