NSG 507 Week 7 Breasts and Axillae

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University of Phoenix

NSG/507 Social Justice and Information Systems for Population Health

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Date

Chapter 18: Breasts and Axillae

Question 1: Breast Cancer Screening (44-year-old woman with a benign breast cyst)

Scenario: A 44-year-old woman presents with a breast mass that is diagnosed as a benign cyst. She has no family history of breast cancer and previously had one screening mammogram at age 43.

Question: What advice regarding breast cancer screening is most appropriate?

Options

• A. Breast self-examination (BSE) should be routinely taught.

• B. Clinical breast examination (CBE) should begin annually at age 30.

• C. She was compliant with USPSTF recommendations for her age and risk factors. ✅

• D. Mammography is most accurate in women in their 40s.

• E. There is no controversy regarding breast cancer screening guidelines.

Correct Answer: C

Key Points

• Average-risk women should follow age-appropriate screening recommendations.

• Routine BSE is not universally recommended because it has not been shown to reduce mortality.

• Breast cancer screening recommendations vary among professional organizations.

Question 2: MRI for Breast Cancer Screening (42-year-old woman)

Scenario: A healthy 42-year-old woman wants to replace mammography with MRI because she is concerned about radiation exposure.

Question: Which statement about breast MRI screening is correct?

Options

• A. MRI is well studied for routine screening in average-risk women.

• B. MRI increases sensitivity but decreases specificity. ✅

• C. She is an ideal MRI screening candidate.

• D. MRI is recommended for women with lifetime breast cancer risk below 20%.

• E. BRCA mutation alone is insufficient for MRI screening.

Correct Answer: B

Key Points

• MRI detects more cancers (higher sensitivity).

• MRI also results in more false-positive findings (lower specificity).

• MRI is primarily recommended for high-risk women (e.g., BRCA mutation carriers or lifetime risk ≥20%).

Question 3: Bilateral Milky Nipple Discharge (35-year-old woman)

Scenario: A woman presents with bilateral milky nipple discharge, irregular menses, negative pregnancy test, and normal thyroid function.

Question: What is the most likely diagnosis?

Options

• A. Mastitis

• B. Ductal carcinoma in situ

• C. Paget disease

• D. Occult pregnancy

• E. Prolactinoma ✅

Correct Answer: E

Key Points

• Bilateral milky discharge (galactorrhea) with menstrual irregularities suggests hyperprolactinemia.

• Pregnancy and hypothyroidism should be excluded before considering prolactinoma.

• Prolactinoma is a common cause of persistent galactorrhea.

Question 4: Breast Self-Examination (22-year-old woman)

Scenario: A young woman discovers a painless breast mass during self-examination and fears breast cancer.

Question: Which statement is correct?

Options

• A. Most self-detected masses are malignant.

• B. Fibroadenoma is more likely than breast cancer. ✅

• C. Breast abscess is the most likely diagnosis.

• D. Imaging is unnecessary because she is young.

• E. BSE has very high sensitivity and specificity.

Correct Answer: B

Key Points

• Fibroadenoma is the most common benign breast tumor in young women.

• Any persistent breast mass should still be evaluated with appropriate imaging.

• Routine BSE is not universally recommended because evidence has not shown improved survival.

Question 5: BRCA Testing (48-year-old woman)

Scenario: A woman has multiple paternal relatives with breast cancer, including her father, and has Ashkenazi Jewish ancestry.

Question: Which statement is true?

Options

• A. Paternal family history is unimportant.

• B. Male breast cancer does not influence BRCA testing.

• C. BRCAPRO adds no clinical value.

• D. She has multiple indications for BRCA testing. ✅

• E. BRCA-positive patients do not require different screening.

Correct Answer: D

Key Points

• Important BRCA risk factors include:

  • Male breast cancer in a first-degree relative.

  • Multiple relatives with breast cancer.

  • Paternal family history.

  • Ashkenazi Jewish ancestry.

• Positive BRCA testing changes screening, surveillance, and preventive management.

High-Yield Takeaways

• Breast self-examination: Not routinely recommended for average-risk women.

• Clinical breast examination: Recommendations vary among organizations.

• MRI screening: Higher sensitivity, lower specificity; reserved for high-risk patients.

• Fibroadenoma: Most common breast mass in young women.

• Galactorrhea + irregular menses: Think prolactinoma after excluding pregnancy and thyroid disease.

• BRCA testing: Consider with strong family history, male breast cancer, and Ashkenazi Jewish ancestry.

Question 6: MRI Screening in a High-Risk Patient

Scenario: A 68-year-old woman has multiple breast cancer risk factors:

• Mother with breast cancer

• Cousin diagnosed before age 50

• Prior chest radiation for lymphoma

• Previous hormone replacement therapy

• Dense breasts with abnormal mammograms (benign biopsies)

Question: Which statement regarding breast MRI screening is correct?

Options

• A. No organization recommends MRI for patients with these risk factors.

• B. USPSTF recommends against MRI screening.

• C. MRI has higher sensitivity but lower specificity than mammography. ✅

• D. Breast density does not affect mammography.

• E. Chest radiation is not a breast cancer risk factor.

Correct Answer: C

High-Yield Points

• Breast MRI is more sensitive than mammography but has more false-positive results.

• MRI is recommended for selected high-risk women, especially those with prior chest radiation or BRCA mutations.

• Dense breast tissue decreases mammographic sensitivity.

Question 7: Supraclavicular Lymphadenopathy

Scenario: A 66-year-old woman has a firm, rubbery, non-tender right supraclavicular lymph node without breast symptoms.

Question: Which statement is correct?

Options

• A. Breast cancer always spreads first to axillary nodes.

• B. Supraclavicular nodes are usually benign.

• C. Supraclavicular nodes lie along the anterior edge of the trapezius.

• D. Firm, rubbery nodes are generally benign.

• E. Breast cancer may spread directly to infraclavicular and supraclavicular nodes without obvious axillary involvement. ✅

Correct Answer: E

High-Yield Points

• Enlarged supraclavicular lymph nodes are always concerning for malignancy.

• Breast lymphatics can spread to:

  • Axillary nodes

  • Infraclavicular nodes

  • Supraclavicular nodes

• Hard, fixed, non-tender nodes strongly suggest metastatic disease.

Question 8: Reporting Breast Mass Location

Scenario: A 24-year-old woman has a mobile, rubbery fibroadenoma in the right breast located 3 cm superior and 3 cm medial to the nipple.

Question: How should the location be documented?

Options

• A. Right breast, 10:30 position from the nipple. ✅

• B. Lower outer quadrant.

• C. Upper inner quadrant.

• D. Left upper outer quadrant.

• E. Right breast, 1:30 position.

Correct Answer

A

High-Yield Points

• Breast lesions are described using:

  • Clock-face position

  • Distance from the nipple

  • Breast side (right/left)

• In the right breast, a lesion superior and medial corresponds approximately to the 10:30 position.

Question 9: Menopausal Changes of the Breast

Scenario: A 54-year-old postmenopausal woman reports that her breasts have become less lumpy.

Question: Which statement is correct?

Options

• A. Fatty replacement decreases mammographic accuracy.

• B. Hormone replacement therapy has no effect on density.

• C. Breast glandular tissue atrophies because the number of lobules decreases. ✅

• D. Breast density has no genetic influence.

• E. Mammography performs worst after menopause.

Correct Answer

C

High-Yield Points

• Menopause causes:

  • Atrophy of glandular tissue

  • Decreased lobules

  • Increased fatty replacement

• Fatty breasts improve mammographic sensitivity.

• Hormone replacement therapy may increase breast density.

High-Yield Summary

MRI Screening

• Higher sensitivity

• Lower specificity

• Best for high-risk patients (BRCA mutation, prior chest radiation, lifetime risk ≥20%)

Lymph Nodes

• Hard, fixed, supraclavicular nodes → suspicious for malignancy

• Breast cancer can spread beyond axillary nodes

Breast Mass Documentation

Always include:

• Side (right/left)

• Clock-face position

• Distance from nipple

• Size

• Consistency

• Mobility

• Tenderness

Menopause

• ↓ Lobules

• ↑ Fat replacement

• ↓ Breast density

• Mammography becomes more accurate

Breasts & Axillae – High-Yield Study Notes

Question 1: Bloody Nipple Discharge

Scenario: A 72-year-old woman has a 3-month history of unilateral bloody nipple discharge and a hard, fixed axillary lymph node.

Options

• A. Benign breast abnormality

• B. Breast cancer ✅

• C. Galactorrhea

Correct Answer: B

High-Yield Points

• Unilateral spontaneous bloody nipple discharge is highly suspicious for breast cancer.

• A hard, fixed axillary node strongly suggests metastatic disease.

• Breast cancer may present without a palpable breast mass.

Question 2: Paget Disease of the Breast

Scenario: A 44-year-old woman has an eczema-like scaly lesion of the nipple with an underlying painless breast mass.

Options

• A. Nipple retraction

• B. Paget disease ✅

• C. Peau d’orange

Correct Answer: B

High-Yield Points

• Paget disease presents as:

  • Persistent eczema-like nipple rash

  • Scaling/crusting

  • Possible ulceration

• Often associated with an underlying breast carcinoma.

• Any nipple eczema that fails topical treatment requires evaluation for malignancy.

Question 3: Nipple Retraction

Scenario: A 56-year-old woman develops a flattened nipple deviating laterally, with a palpable breast mass and fixed axillary nodes.

Options

• A. Nipple retraction ✅

• B. Paget disease

• C. Peau d’orange

Correct Answer: A

High-Yield Points

• Nipple retraction is a late sign of breast cancer.

• Caused by fibrosis pulling the nipple inward.

• Frequently associated with invasive carcinoma.

Question 4: Clear Nipple Discharge

Scenario: A 19-year-old woman has clear unilateral discharge only when the nipple is squeezed. Pregnancy test is negative.

Options

• A. Benign breast abnormality ✅

• B. Breast cancer

• C. Nonpuerperal galactorrhea

Correct Answer: A

High-Yield Points

• Clear discharge that is:

  • Expressed only with compression

  • Unilateral

  • Non-bloody

  • No mass present
    → Usually benign.

• Advise the patient to stop repeatedly expressing the nipple before further workup.

NSG 507 Week 7 Breasts and Axillae

Question 5: Acanthosis Nigricans

Scenario: A 23-year-old obese woman with acne and irregular menses has dark, velvety axillary skin.

Options

• A. Peau d’orange

• B. Acanthosis nigricans ✅

• C. Hidradenitis suppurativa

Correct Answer; B

High-Yield Points

• Associated with:

  • Insulin resistance

  • Obesity

  • Polycystic ovary syndrome (PCOS)

  • Type 2 diabetes

• Rarely associated with internal malignancy.

Question 6: Infectious Axillary Lymphadenopathy

Scenario: A 43-year-old woman has a painful, red, warm, movable axillary lymph node after cutting her hand while gardening.

Options

• A. Breast cancer

• B. Infectious lymphadenopathy ✅

• C. Hidradenitis suppurativa

Correct Answer: B

High-Yield Points

• Infection causes lymph nodes that are:

  • Tender

  • Warm

  • Mobile

  • Erythematous

• Always examine the skin draining into the affected lymph node for cuts, bites, or scratches.

High-Yield Summary

Breast Cancer Clues

• Bloody unilateral nipple discharge

• Hard, fixed lymph nodes

• Nipple retraction

• Paget disease

Benign Findings

• Clear discharge only with nipple compression

• Tender, mobile, warm lymph nodes → infection

Skin Findings

• Paget disease: Scaly nipple lesion

• Acanthosis nigricans: Dark velvety axilla (insulin resistance)

• Peau d’orange: Edematous “orange peel” skin caused by lymphatic obstruction in breast cancer

Question 12: Palpable Mass Under the Male Areola

Scenario: A 30-year-old man notices a firm 2-cm mass beneath the areola. No symptoms or family history of breast cancer.

Options

• A. Normal breast tissue ✅

• B. Fibrocystic disease

• C. Breast cancer

• D. Lymph node

Correct Answer

A

High-Yield Points

• Approximately one-third of adult men have palpable breast tissue beneath the areola.

• Male breast cancer is uncommon.

• There are no lymph nodes directly beneath the areola.

Question 13: Axillary Lymph Nodes in Breast Cancer

Question

Which axillary lymph node group is most commonly involved in breast cancer?

Options

• A. Lateral

• B. Subscapular

• C. Pectoral

• D. Central ✅

Correct Answer: D

High-Yield Points

• The central axillary nodes are most commonly involved.

• During examination, palpate:

  • Central

  • Pectoral

  • Lateral

  • Subscapular

  • Apex of the axilla

Question 14: Timing of Breast Self-Examination (BSE)

Question

When should BSE be performed?

Options

• A. 5–7 days after menstruation begins (or after menses ends) ✅

• B. Mid-cycle

• C. Immediately before menses

• D. During menses

Correct Answer: A

High-Yield Points

• Perform BSE when hormonal stimulation is lowest.

• Breasts are least tender and least swollen shortly after menstruation.

Question 15: Risk That a Breast Mass Is Malignant

Scenario: A 48-year-old woman presents with a breast mass.

Options

• A. About 10% ✅

• B. About 20%

• C. About 30%

• D. About 40%

Correct Answer: A

High-Yield Points

• Roughly 1 in 10 (≈11%) women presenting with a breast mass have breast cancer.

• Although most masses are benign, every new breast mass requires evaluation.

Question 16: Clinical Breast Examination (ACS Recommendation)

Question

How often should a skilled clinician perform a screening breast examination?

Options

• A. Every year

• B. Every 2 years

• C. Every 3 years ✅

• D. Every 4 years

Correct Answer: C

High-Yield Points

• (Based on the Bates edition referenced.) Clinical breast examination was recommended every 3 years for younger women.

• Note: Current screening recommendations vary among organizations and have changed over time.

Question 17: Benign Breast Finding

Question

Which finding is most likely benign?

Options

• A. Peau d’orange

• B. One breast larger than the other ✅

• C. Newly inverted nipple

• D. Skin dimpling with forward leaning

Correct Answer: B

High-Yield Points

• Mild breast asymmetry is common.

• Concerning findings include:

  • Skin dimpling

  • Peau d’orange

  • Recent nipple inversion/retraction

Question 18: Best Palpation Technique

Question

Which palpation pattern is most effective?

Options

• A. Spiral

• B. Quadrant

• C. Vertical strip (“lawn-mower”) pattern ✅

• D. Radial spokes

Correct Answer: C

High-Yield Points

• The vertical strip pattern has the highest detection rate.

• Always include the Tail of Spence (axillary tail) during examination.

Question 19: Examination After Unilateral Mastectomy

Question

Which statement is correct?

Options

• A. No further breast examinations are necessary.

• B. Examine the surgical scar carefully for recurrence. ✅

• C. Ipsilateral arm lymphedema usually indicates recurrence.

• D. Reconstruction eliminates the need for examination.

Correct Answer: B

High-Yield Points

• Women remain at risk for:

  • Local recurrence

  • Contralateral breast cancer

• Examine:

  • Surgical scar

  • Remaining breast

  • Axillary lymph nodes

• Lymphedema is a common postoperative complication and does not necessarily indicate recurrence.

Question 20: Breast Self-Examination (BSE)

Question

Which statement about BSE is true?

Options

• A. It reduces breast cancer mortality.

• B. It is recommended by every screening organization.

• C. Many breast masses are first detected during BSE. ✅

• D. Anxiety caused by BSE means it should not be taught.

Correct Answer

C

High-Yield Points

• Many breast abnormalities are first noticed by patients.

• However:

  • BSE has not been proven to reduce mortality.

  • Recommendations differ among professional organizations.

• Women who choose to perform BSE should be taught a systematic examination technique.

Exam Pearls (Questions 12–20)

Normal Findings

• Palpable breast tissue beneath the male areola

• Mild breast asymmetry

Suspicious Findings

• Peau d’orange

• Skin dimpling

• Recent nipple inversion

• Hard, fixed lymph nodes

Breast Examination

• Best palpation: Vertical strip pattern

• Include the Tail of Spence

• Perform BSE 5–7 days after menstruation

After Mastectomy

• Continue lifelong surveillance.

• Carefully inspect and palpate the scar, remaining breast, and regional lymph nodes.

Screening

• BSE helps detect many breast masses but has not been shown to reduce mortality.

• Screening recommendations vary by guideline and patient risk.

Question 1: Breast Anatomy

Question: Which tissues primarily make up the breast?

Options

• A. Mostly muscle

• B. Fibrous, glandular, and adipose tissue ✅

• C. Mostly lactiferous ducts

• D. Glandular tissue attached to chest wall

Correct Answer: B

High-Yield Points

• Breast tissue consists of:

  • Glandular tissue (lobes/lobules)

  • Fibrous connective tissue (Cooper ligaments)

  • Adipose tissue

• The breast contains very little muscle.

Question 2: Upper Outer Quadrant

Question: Why is the upper outer quadrant examined carefully?

Options

• A. Largest quadrant

• B. Most breast tumors occur here ✅

• C. Contains most suspensory ligaments

• D. Most prone to calcification

Correct Answer: B

High-Yield Points

• Most breast cancers develop in the upper outer quadrant.

• Includes the Tail of Spence, which extends into the axilla.

Question 3: Axillary Lymph Nodes

Question: Which axillary lymph node groups should be examined?

Options

• A. Central, axillary, lateral, sternal

• B. Pectoral, lateral, inferior, sternal

• C. Central, lateral, pectoral, and subscapular ✅

• D. Lateral, pectoral, axillary, suprascapular

Correct Answer: C

High-Yield Points

Four major axillary node groups:

• Central

• Pectoral (anterior)

• Subscapular (posterior)

• Lateral (humeral)

Question 4: Breast Infection

Question: A recent breast infection usually enlarges which lymph nodes?

Options

• A. Nonspecific

• B. Ipsilateral axillary nodes ✅

• C. Contralateral axillary nodes

• D. Inguinal and cervical nodes

Correct Answer: B

High-Yield Points

• Over 75% of breast lymph drains to the same-side (ipsilateral) axillary lymph nodes.

Question 5: Breast Development in a 9-Year-Old Girl

Question: What is the best nursing response?

Options

• A. “Don’t worry.”

• B. “I was a late bloomer too.”

• C. “You’ll menstruate before your breasts grow.”

• D. Breast development usually begins between ages 8–10 years. ✅

Correct Answer: D

High-Yield Points

• Breast budding normally begins 8–10 years.

• Menarche typically occurs about 2 years after breast development begins.

• Acknowledge the child’s concerns rather than dismissing them.

Question 6: Unilateral Breast Enlargement in a 10-Year-Old

Question: A mother reports one breast is enlarging and tender.

Options

• A. Abnormal—needs urgent evaluation.

• B. Breast cancer is common.

• C. Temporary asymmetry is usually normal. ✅

• D. Tenderness is unusual.

Correct Answer: C

High-Yield Points

• During puberty:

  • One breast may develop before the other.

  • Mild tenderness is common.

• Reassurance is appropriate unless other concerning findings exist.

Question 7: Delayed Menarche

Question: Which history is most helpful?

Options

• A. Age breast development began ✅

• B. Mother’s age at breast development

• C. Pubic hair onset

• D. Axillary hair onset

Correct Answer: A

High-Yield Points

• Menarche usually occurs about 2 years after breast budding.

• Breast development is the best predictor of pubertal progression.

Question 8: Cyclic Breast Changes

Question: A woman reports her breasts change throughout the month.

Options

• A. This is unusual.

• B. Due to stress.

• C. Hormonal changes during the menstrual cycle cause cyclic breast changes. ✅

• D. Changes occur only in pregnancy.

Correct Answer: C

High-Yield Points

• Premenstrual changes include:

  • Fullness

  • Tenderness

  • Heaviness

• Breasts are least swollen 4–7 days after menstruation begins