NSG 3160 EXAM
3
BREAST, CARDIOVASCULAR, PERIPHERAL
VASCULAR, LYMPHATIC & RESPIRATORY
ASSESSMENT
CORRECT ANSWERS + DETAILED RATIONALES
PART I — BREAST ASSESSMENT
1. During an annual physical examination, a 43-year-old patient states
that she does not perform monthly breast self-examinations (BSEs). She
tells the nurse that she believes that mammograms do a much better job
than she ever could to find a lump. The nurse should explain that:
Correct Answer: BSEs may detect lumps that appear between mammograms.
Rationale: A person should be familiar with the normal appearance and feel of their
breasts and report new changes promptly. Mammography is an important screening
tool, but breast changes can occur between screening examinations. Current
,American Cancer Society guidance, however, does not recommend routine BSE as a
formal screening test; it emphasizes breast self-awareness instead.
2. 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
information. Which statement by the nurse is accurate?
Correct Answer: Breastfeeding provides ideal nutrition and antibodies for the baby.
Rationale: Breast milk provides appropriate nutrients and contains immunologic
components, including antibodies, that help protect the infant. Exclusive
breastfeeding for approximately the first 6 months is recommended when possible.
3. Which woman has a breast-cancer risk factor that places her at higher
risk?
Correct Answer: A 65-year-old woman whose mother had breast cancer.
Rationale: Increasing age and a first-degree family history of breast cancer are
important risk factors. A mother with breast cancer can indicate increased familial
risk.
4. During examination of a woman, the nurse notices that her left breast is
slightly larger than her right. Which statement is true?
Correct Answer: Asymmetry is not unusual, but the nurse should verify that this
change is not new.
Rationale: Mild breast asymmetry is common. What is more concerning is a new or
progressive change, particularly when associated with a mass, skin changes, nipple
retraction, or discharge.
,5. Which finding during breast inspection would be considered abnormal?
Correct Answer: Nipples located in different planes/deviated from their normal
position.
Rationale: A difference in nipple position can indicate an underlying mass or tissue
retraction. The nurse should investigate whether the finding is new.
6. During physical examination, the nurse notices an inverted left nipple.
What is the most accurate interpretation?
Correct Answer: Determine whether the inversion is a recent change.
Rationale: Long-standing nipple inversion may be a normal variation. New unilateral
nipple inversion, particularly in an adult, requires further assessment because it
may indicate an underlying breast lesion.
7. What is the correct technique for screening for nipple and skin
retraction?
Correct Answer: Ask the woman to slowly raise her arms above her head and
observe for retraction or lag in movement.
Rationale: Raising the arms stretches the breast tissue and can make dimpling,
fixation, or retraction more apparent.
8. Which position makes significant breast lumps most distinct during
palpation?
Correct Answer: Supine with the arm raised over the head.
Rationale: The breast tissue spreads over the chest wall when the patient is supine.
Raising the arm further flattens the breast tissue, making masses easier to identify.
, 9. Which clinical situation is outside normal limits?
Correct Answer: A woman who stopped breastfeeding 10 years ago and now has
thick yellow discharge from both nipples.
Rationale: Nipple discharge long after lactation should be assessed rather than
automatically attributed to previous breastfeeding. Important assessment points
include color, amount, whether it is spontaneous or expressed, unilateral versus
bilateral presentation, and medications.
10. A patient reports a new lump in the left breast near the axilla. What
should the nurse do first?
Correct Answer: Palpate the unaffected breast first.
Rationale: Examining the unaffected breast first establishes the patient's baseline
and helps decrease anxiety before assessing the area of concern.
11. A nurse documents a breast mass as small, round, firm, distinct,
located at 2 o'clock, 2 cm from the nipple, nontender and fixed. What
information is missing?
Correct Answer: The size of the mass.
Rationale: A breast mass should be documented using its location, size, shape,
consistency, mobility, borders/distinctness, tenderness, nipple findings, skin
changes, and regional lymph-node findings.
12. When is the best time for a menstruating woman to perform a breast
self-examination?
Correct Answer: About 4–7 days after the first day of menstruation.
3
BREAST, CARDIOVASCULAR, PERIPHERAL
VASCULAR, LYMPHATIC & RESPIRATORY
ASSESSMENT
CORRECT ANSWERS + DETAILED RATIONALES
PART I — BREAST ASSESSMENT
1. During an annual physical examination, a 43-year-old patient states
that she does not perform monthly breast self-examinations (BSEs). She
tells the nurse that she believes that mammograms do a much better job
than she ever could to find a lump. The nurse should explain that:
Correct Answer: BSEs may detect lumps that appear between mammograms.
Rationale: A person should be familiar with the normal appearance and feel of their
breasts and report new changes promptly. Mammography is an important screening
tool, but breast changes can occur between screening examinations. Current
,American Cancer Society guidance, however, does not recommend routine BSE as a
formal screening test; it emphasizes breast self-awareness instead.
2. 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
information. Which statement by the nurse is accurate?
Correct Answer: Breastfeeding provides ideal nutrition and antibodies for the baby.
Rationale: Breast milk provides appropriate nutrients and contains immunologic
components, including antibodies, that help protect the infant. Exclusive
breastfeeding for approximately the first 6 months is recommended when possible.
3. Which woman has a breast-cancer risk factor that places her at higher
risk?
Correct Answer: A 65-year-old woman whose mother had breast cancer.
Rationale: Increasing age and a first-degree family history of breast cancer are
important risk factors. A mother with breast cancer can indicate increased familial
risk.
4. During examination of a woman, the nurse notices that her left breast is
slightly larger than her right. Which statement is true?
Correct Answer: Asymmetry is not unusual, but the nurse should verify that this
change is not new.
Rationale: Mild breast asymmetry is common. What is more concerning is a new or
progressive change, particularly when associated with a mass, skin changes, nipple
retraction, or discharge.
,5. Which finding during breast inspection would be considered abnormal?
Correct Answer: Nipples located in different planes/deviated from their normal
position.
Rationale: A difference in nipple position can indicate an underlying mass or tissue
retraction. The nurse should investigate whether the finding is new.
6. During physical examination, the nurse notices an inverted left nipple.
What is the most accurate interpretation?
Correct Answer: Determine whether the inversion is a recent change.
Rationale: Long-standing nipple inversion may be a normal variation. New unilateral
nipple inversion, particularly in an adult, requires further assessment because it
may indicate an underlying breast lesion.
7. What is the correct technique for screening for nipple and skin
retraction?
Correct Answer: Ask the woman to slowly raise her arms above her head and
observe for retraction or lag in movement.
Rationale: Raising the arms stretches the breast tissue and can make dimpling,
fixation, or retraction more apparent.
8. Which position makes significant breast lumps most distinct during
palpation?
Correct Answer: Supine with the arm raised over the head.
Rationale: The breast tissue spreads over the chest wall when the patient is supine.
Raising the arm further flattens the breast tissue, making masses easier to identify.
, 9. Which clinical situation is outside normal limits?
Correct Answer: A woman who stopped breastfeeding 10 years ago and now has
thick yellow discharge from both nipples.
Rationale: Nipple discharge long after lactation should be assessed rather than
automatically attributed to previous breastfeeding. Important assessment points
include color, amount, whether it is spontaneous or expressed, unilateral versus
bilateral presentation, and medications.
10. A patient reports a new lump in the left breast near the axilla. What
should the nurse do first?
Correct Answer: Palpate the unaffected breast first.
Rationale: Examining the unaffected breast first establishes the patient's baseline
and helps decrease anxiety before assessing the area of concern.
11. A nurse documents a breast mass as small, round, firm, distinct,
located at 2 o'clock, 2 cm from the nipple, nontender and fixed. What
information is missing?
Correct Answer: The size of the mass.
Rationale: A breast mass should be documented using its location, size, shape,
consistency, mobility, borders/distinctness, tenderness, nipple findings, skin
changes, and regional lymph-node findings.
12. When is the best time for a menstruating woman to perform a breast
self-examination?
Correct Answer: About 4–7 days after the first day of menstruation.
