Test 3 Review Flashcards
The primary purpose of the ciliated mucous membrane in the nose is to:
A. Warm the inhaled air.
B. Filter out dust and bacteria.
C. Filter coarse particles from inhaled air.
D. Facilitate the movement of air through the nares.
ANS: B
The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.
The projections in the nasal cavity that increase the surface area are called the: A. Meatus. B. Septum. C. Turbinates D. Kiesselbach plexus.
ANS: C
The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air.
The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?
a. Sphenoid sinuses are full size at birth.
b. Maxillary sinuses reach full size after puberty.
c. Frontal sinuses are fairly well developed at birth.
d. Maxillary and ethmoid sinuses are the only sinuses present at birth.
ANS: D
Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.
The tissue that connects the tongue to the floor of the mouth is the: A. Uvula B. Palate C. Papillae D. Frenulum.
ANS: D
The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongues dorsal surface.
The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland.
a. Parotid
b. Stensens
c. Sublingual
d. Submandibular
ANS: A
The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensens duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw
In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings?
a. Refer the patient to a throat specialist.
b. No response is needed; this appearance is normal for the tonsils.
c. Continue with the assessment, looking for any other abnormal findings.
d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.
ANS: B
The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.
The nurse is obtaining a health history on a 3 month old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurses best response would be:
a. Youre right, drooling is usually a sign of the first tooth.
b. It would be unusual for a 3 month old to be getting her first tooth.
c. This could be the sign of a problem with the salivary glands.
d. She is just starting to salivate and hasnt learned to swallow the saliva.
ANS: D
In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?
a. Hypertrophy of the gums
b. Increased production of saliva
c. Decreased ability to identify odors
d. Finer and less prominent nasal hair
ANS: C
The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.
The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is:
a. Leukoedema and is common in dark-pigmented persons.
b. The result of hyperpigmentation and is normal.
c. Torus palatinus and would normally be found only in smokers.
d. Indicative of cancer and should be immediately tested.
ANS: A
Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurses best response?
a. While sitting up, place a cold compress over your nose.
b. Sit up with your head tilted forward and pinch your nose.
c. Just allow the bleeding to stop on its own, but dont blow your nose.
d. Lie on your back with your head tilted back and pinch your nose.
ANS: B
With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
a. Epistaxis
b. Rhinorrhea
c. Dysphagia
d. Xerostomia
ANS: C
Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth.
While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The best response by the nurse would be:
a. Youre right. Bottles make very good pacifiers.
b. Using a bottle as a pacifier is better for the teeth than thumb-sucking.
c. Its okay to use a bottle as long as it contains milk and not juice.
d. Prolonged use of a bottle can increase the risk for tooth decay and ear infections.
ANS: D
Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be:
a. Do you use a fluoride supplement?
b. Have you had tonsillitis in the last year?
c. At what age did you get your first tooth?
d. Have you noticed any dryness in your mouth?
ANS: D
Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators.
he nurse is using an otoscope to assess the nasal cavity. Which of these techniques iscorrect?
a. Inserting the speculum at least 3 cm into the vestibule
b. Avoiding touching the nasal septum with the speculum
c. Gently displacing the nose to the side that is being examined
d. Keeping the speculum tip medial to avoid touching the floor of the nares
ANS: B
The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.
The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
a. Are you aware of having any allergies?
b. Do you have an elevated temperature?
c. Have you had any symptoms of a cold?
d. Have you been having frequent nosebleeds?
ANS: A
With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes.
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
ANS: B
The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?
a. Check the patients hemoglobin for anemia
b. Assess for other signs of insufficient oxygen supply.
c. Proceed with the assessment, knowing that this appearance is a normal finding.
d. Ask if he has been exposed to an excessive amount of carbon monoxide.
ANS: C
Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
a. Dehydration.
b. Irritation by gastric juices.
c. A normal oral assessment.
d. Side effects from nausea medication.
ANS: A
Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures. DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?
a. These spots indicate an infection such as strep throat.
b. These bumps could be indicative of a serious lesion, so I will refer you to a specialist.
c. This condition is called leukoplakia and can be caused by chronic irritation such as with smoking.
d. These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition.
ANS: D
Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.
A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection?
a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
b. Tonsils 2+/1-4+ with small plugs of white debris
c. Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring
ANS: C
With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?
a. Attempt to suction again with a bulb syringe.
b. Wait a few minutes, and try again once the infant stops crying.
c. Recognize that this situation requires immediate intervention.
d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.
ANS: C
Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects that child abuse is involved. During an inspection of the mouth, the nurse should look for…
a. Swollen, red tonsils.
b. Ulcerations on the hard palate.
c. Bruising on the buccal mucosa or gums.
d. Small yellow papules along the hard palate.
ANS: C
The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.
The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?
a. Refer to the physician for an antibiotic order.
b. Have the mother bring the child back in 1 week.
c. Perform an otoscopic examination of the left nares.
d. Tell the mother that this drainage is normal for a child of this age.
ANS: C
Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.
During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?
a. Tell the patient she needs to see a skin specialist.
b. Discuss the benefits of having a biopsy performed on any unusual lesion.
c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days.
d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.
ANS: C
Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
a. Nutritional status
b. When the patient first noticed the lesion
c. Whether the patient has had a recent cold
d. Whether the patient has had any recent exposure to sick animals
ANS: B
With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse?
a. Your condition is probably due to a vitamin C deficiency.
b. Im not sure what causes swollen and bleeding gums, but let me know if its not better in a few weeks.
c. You need to make an appointment with your dentist as soon as possible to have this checked.
d. Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy.
ANS: D
Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:
a. Aphthous ulcers.
b. Candidiasis.
c. Leukoplakia.
d. Koplik spots.
ANS: B
Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed.
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
a. We will need to get a biopsy to determine the cause.
b. This is an overgrowth of hair and will go away in a few days.
c. Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.
d. This is probably caused by the same bacteria you had in your lungs.
ANS: C
A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.
The nurse is assessing a patient with a history of intravenous drug abuse. In asseessing his mouth, the nurse notices a dark red conflulent macule on the hard palate. This could be a sign of..
a. Acquired immunodeficiency syndrome (AIDS).
b. Measles.
c. Leukemia.
d. Carcinoma.
ANS: A
Oral Kaposis sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.
A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother?
a. This area of irritation is caused from teething and is nothing to worry about.
b. This finding is abnormal and should be evaluated by another health care provider.
c. This area of irritation is the result of chronic drooling and should resolve within the next month or two.
d. This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal.
ANS: D
A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurses best response would be:
a. How many teeth did you have at this age?
b. All 20 deciduous teeth are expected to erupt by age 4 years.
c. This is a normal number of teeth for an 18 month old.
d. Normally, by age 2 years, 16 deciduous teeth are expected.
ANS: C
The guidelines for the number of teeth for children younger than 2 years old are as follows: the childs age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.
When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?
a. Teeth appearing shorter
b. Tongue that looks smoother in appearance
c. Buccal mucosa that is beefy red in appearance
d. Small, painless lump on the dorsum of the tongue
ANS: B
In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.
- When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?
a. Nasal polyps
b. Acute sinusitis
c. Allergic rhinitis
d. Acute rhinitis
ANS: C
Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical
examination, serous edema is noted, and the buccal mucosa appears pale with a smooth, glistening surface.
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:
a. Smooth glossy dorsal surface.
b. Thin white coating over the tongue.
c. Raised papillae on the dorsal surface.
d. Visible venous patterns on the ventral surface.
ANS: A
The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis.
The nurse is performing an assessment. Which of these findings would cause the greatest concern?
a. Painful vesicle inside the cheek for 2 days
b. Presence of moist, nontender Stensens ducts
c. Stippled gingival margins that snugly adhere to the teeth
d. Ulceration on the side of the tongue with rolled edges
ANS: D
Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings.
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?
a. Rubella
b. Leukoplakia
c. Rheumatic fever
d. Scarlet fever
ANS: C
Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.
- During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
a. You should never use over-the-counter nasal sprays because of the risk of addiction.
b. You should try switching to another brand of medication to prevent this problem.
c. Continuing to use this spray is important to keep your allergies under control.
d. Using these nasal medications irritates the lining of the nose and may cause rebound swelling.
ANS: D
The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?
a. This condition is a cleft palate and is common in Native Americans.
b. A bifid uvula may occur in some Native-American groups.
c. This condition is due to an injury and should be reported to the authorities.
d. A bifid uvula is palatinus, which frequently occurs in Native Americans.
ANS: B
Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native- American groups.
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
a. Posterior epistaxis.
b. Frontal sinusitis.
c. Maxillary sinusitis.
d. Nasal polyps.
ANS: C
Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.
A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of:
a. A problem with the patients coagulation system.
b. Increased vascularity in the upper respiratory tract as a result of the pregnancy.
c. Increased susceptibility to colds and nasal irritation.
d. Inappropriate use of nasal sprays.
ANS: B
Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.
The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply.
a. One pinch of SLT in the mouth for more than 30 minutes delivers the equivalent of one cigarette.
b. Using SLT has been associated with a greater risk of oral cancer than smoking.
c. Pain is an early sign of oral cancer.
d. Pain is rarely an early sign of oral cancer.
e. Tooth decay is another risk of SLT because of the use of sugar as a sweetener.
f. SLT is considered a healthy alternative to smoking.
ANS: B, D, E
One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking.
During an assessment, a patient mentions that I just cant smell like I used to. I can barely smell the roses in my garden. Why is that? For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply
a. Chronic alcohol use
b. Cigarette smoking
c. Frequent episodes of strep throat
d. Chronic allergies
e. Aging
f. Herpes simplex virus I
ANS: B, D, E
The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.
Which of the following statements is true regarding the internal structures of the breast? The breast is made up of:
A. Primarily muscle with very little fibrous tissue.
B. Fibrous, glandular, and adipose tissues.
C. Primarily milk ducts, known as lactiferous ducts.
D. Glandular tissue, which supports the breast by attaching to the chest wall.
ANS: B
The breast is made up of glandular, fibrous (including the suspensory ligaments), and adipose tissues.
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. 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 womans axillary lymph system, the nurse should assess which of these nodes?
a. Central, axillary, lateral, and sternal
b. Pectoral, lateral, anterior, and sternal
c. Central, lateral, pectoral, and subscapular
d. Lateral, pectoral, axillary, and suprascapular
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 sport physical examination. After some initial shyness she finally asks, Am I normal? I dont seem to need a bra yet, but I have some friends who do. What if I never get breasts? The nurses best response would be:
a. Dont 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 girls feelings by using statements like dont worry or by sharing personal experiences. The beginning of breast development precedes menarche by approximately 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 nurses best response? Tell the mother that:
a. Breast development is usually fairly symmetric and that the daughter should be examined right away.
b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls.
c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal.
d. It is unusual for breasts that are first developing to feel tender because they havent developed much fibrous tissue.
ANS: C
Occasionally, one breast may grow faster than the other, producing a temporary asymmetry, which may cause some distress; reassurance is necessary. Tenderness is also common.
A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that:
a. The girl 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 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 approximately 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.
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 nurses best response? The nurse should tell her that:
a. Continual changes in her breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long.
b. Breast changes in response to stress are very common and that she should assess her life for stressful events.
c. Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.
d. 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 immediately report these.
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 their original color). A venous pattern is an expected finding and prominent over the skin surface and does not need to be reported. After the fourth month of pregnancy, 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 immediately present after the delivery of your 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 nutrients as breast milk.
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; therefore, breastfeeding is important.
A 65-year-old patient remarks that she just cannot believe that her breasts sag so much. She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:
A. Only women with large breasts experience sagging.
B. A diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging.
D. 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 also atrophies, beginning in the middle years and becoming significant in the eighth and ninth decades of life. These changes decrease breast size and elasticity; consequently, 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 nurses best course of action?
a. Recommend that he make an appointment with his physician for a mammogram.
b. Ignore it. Benign breast enlargement in men is not unusual.
c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician.
d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.
ANS: C
Gynecomastia may reappear in the aging man and may be attributable to a 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 the young girl if her periods have started.
b. Assess the girls weight and body mass index (BMI).
c. Ask the girls mother at what age she started to develop breasts.
d. Nothing; breast budding 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 black 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 developing breast cancer?
a. Black
b. White
c. Asian
d. American Indian
ANS: A
The incidence of breast cancer varies within different cultural groups. White women have a higher incidence of breast cancer than black women starting at age 45 years; but black women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer
The nurse is preparing for a class in early detection of breast cancer. Which statement istrue with regard to breast cancer in black women in the United States?
a. Breast cancer is not a threat to black women.
b. Black women have a lower incidence of regional or distant breast cancer than white women.
c. Black women are more likely to die of breast cancer at any age.
d. Breast cancer incidence in black women is higher than that of white women after age 45.
ANS: C
Black 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, black women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. These racial differences in mortality rates may be related to an insufficient use of screening measures and a lack of access to health care.
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurses most appropriate response to this would be:
a. Dont 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 patients pain rather than make statements that ignore the patients concerns.
During a health 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. Immediately contact the physician to report the discharge.
b. Ask her if she is possibly pregnant.
c. Ask the patient 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 normally 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 approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask?
a. Is the rash raised and red?
b. Does it appear to be cyclic?
c. Where did the rash first appearon 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
The location where the rash first appeared is important for the nurse to determine. Paget disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at the nipple unless it is a result of breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple.
A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? The presence of benign breast disease:
a. Makes it hard to examine the breasts.
b. Frequently turns into cancer in a womans 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 hard to examine the breasts; the general lumpiness of the breast conceals a new lump. The other statements are not true.
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 I ever could to find a lump. The nurse should explain to her that:
a. BSEs may detect lumps that appear between mammograms.
b. BSEs are unnecessary until the age of 50 years.
c. She is correctmammography is a good replacement for BSE.
d. She does not need to perform BSEs as long as a physician checks her breasts annually.
ANS: A
The monthly practice of BSE, 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?
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 of age.
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. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.
c. Asymmetry is not unusual, but the nurse should verify that this change is not new.
d. Asymmetry of breast size and shape 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 BSE 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 may cause fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings.
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. Unilateral inversion of a nipple is always a serious sign.
c. Whether the inversion is a recent change should be determined.
d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
ANS: C
The nurse should distinguish between 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; that is, if it is not fixed. Recent nipple retraction signifies acquired disease.
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, and note any lag or retraction.
d. Slowly lift her arms above her head, and note any retraction or lag in movement.
ANS: D
The woman should be directed to change position while checking the breasts for signs of skin retraction. Initially, she should be asked 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 whether movement of one breast is lagging.
