19

CHAPTER
Breasts and Lymphatic
System

Chapter Overview
Breast and lymphatic health is an important issue, not only for women during their childbearing
years and throughout their lives, but also for men, whose breast development and health may be
affected by various factors such as medications and hormonal problems. Use the following exercises
and quizzes to guide your physical assessment of the breast and lymphatic structures.

CHAPTER PRETEST
Activity A MULTIPLE CHOICE
Choose the best answer for each of the following multiple-choice questions.
1. At puberty, the female breasts enlarge in response to estrogen and
a. progesterone.
b. aldosterone.
c. lactogen.
d. prolactin.
2. Elevated sebaceous glands, known as Montgomery’s glands, are located in the breast’s
a. nipples.
b. hair follicles.
c. lactiferous ducts.
d. areolas.
3. The functional part of the breast that allows for milk production consists of tissue termed
a. fibrous.
b. glandular.
c. adipose.
d. lactiferous.

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 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM 133

4. Fibrous tissue that provides support for the glandular tissue of the breasts is termed
a. lateral ligaments.
b. Wharton’s ligaments.
c. pectoral ligaments.
d. Cooper’s ligaments.
5. The size and shape of the breasts in females is related to the amount of
a. glandular tissue.
b. fibrous tissue.
c. lactiferous ducts.
d. fatty tissue.
6. The lymph nodes that are responsible for drainage from the arms are the
a. lateral lymph nodes.
b. central lymph nodes.
c. anterior lymph nodes.
d. posterior lymph nodes.

Activity B LABELING ACTIVITIES

Label the following structures of the anterior chest.

Landmarks and their position in the thorax.

Label the structure indicated by the line; then match your answer with the label on the matching
figure in Chapter 19 of your textbook.

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134 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM

Label the following breast quadrants.

Breast quadrants.

Label the structure indicated by the line; then match your answer with the label on the matching
figure in Chapter 19 of your textbook.
Label the internal anatomic structures of the breast.

Internal anatomy of the breast.

Label the structure indicated by the line; then match your answer with the label on the matching
figure in Chapter 19 of your textbook.

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 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM 135

Label the following major axillary lymph nodes.

The major axillary lymph nodes.

Label the structure indicated by the line; then match your answer with the label on the matching
figure in Chapter 19 of your textbook.

Activity C LEARNER ACTIVITIES

Working with peers in learning lab
After reading Chapter 19, participate in the following learning activities.
1. Review the information in “Promote Health: Breast Cancer” in Chapter 19 in your textbook.
Determine your own risk of breast cancer. Next, identify ethnic groups that are at higher risk for
breast cancer.
2. Use a breast model to review the anatomy and function of each anatomic structure. Discuss the
changes of the breast and surrounding tissue that occur with aging.
3. Obtain an information packet from a local agency that performs mammograms. Review the mate-
rial with a lab partner, and discuss how you would teach a client to do a breast self-examination.

Activity D INTERVIEWING AND RECORDING ASSESSMENT FINDINGS

Use the following Nursing History Checklist as your guide to interviewing and recording your find-
ings in a breast assessment.

Nursing History Checklist

Satisfactory Needs Additional Data
Questions Data Data Missing

Current Symptoms

1. Changes in breasts (lumps, swelling, redness,

warmth, dimpling, size, firmness, pain, discharge)?

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136 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM

Satisfactory Needs Additional Data

Questions Data Data Missing

Past History

1. Previous problems with breasts (treatment

and surgery)?

2. Age at menses?

3. Age at menopause?

4. Given birth?

5. Age at first birth?

6. First and last day of menstrual cycle?

Family History

1. Family history of breast cancer?

Lifestyle and Health Practices

1. Use of hormones, contraceptives, or antidepressants?

2. Exposure to radiation, benzene, or asbestos?

3. Usual diet, including intake of alcohol, coffee, tea,

soft drinks, and chocolate?

4. Usual exercise patterns?

5. Type of bra worn during exercise?

6. Examine own breasts/frequency?

7. Last breast exam by physician?

8. Last mammogram?

Activity E PERFORMING PHYSICAL ASSESSMENT

Use the following Physical Assessment Checklist as your guide to performing a breast assessment.
Column 1 can be used by you to guide your physical assessment. Column 2 may be used by your
instructor to evaluate your skills as necessary.

Physical Assessment Checklist

Findings Performance
(Normal or (Satisfactory,
Abnormal) Needs Improvement,
and Notes Unsatisfactory)

Assessment Skill N A S N U

1. Gather equipment (centimeter ruler, small pillow, gloves, client 䊐 䊐 䊐 䊐 䊐

handout on breast self-examination, slide for specimen).

2. Explain procedure to client. 䊐 䊐 䊐 䊐 䊐

3. Ask client to put on a gown. 䊐 䊐 䊐 䊐 䊐

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 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM 137

Findings Performance
(Normal or (Satisfactory,
Abnormal) Needs Improvement,
and Notes Unsatisfactory)

Assessment Skill N A S N U

Female Breasts

1. Inspect breasts
a. Size and symmetry 䊐 䊐 䊐 䊐 䊐
b. Color and texture 䊐 䊐 䊐 䊐 䊐
c. Superficial venous patterns 䊐 䊐 䊐 䊐 䊐
d. Retraction and dimpling 䊐 䊐 䊐 䊐 䊐
e. Bilaterally, note color, size, shape, and texture of areolas 䊐 䊐 䊐 䊐 䊐
f. Bilaterally, note size and direction of nipples 䊐 䊐 䊐 䊐 䊐
2. Palpate breasts
a. Texture and elasticity 䊐 䊐 䊐 䊐 䊐
b. Tenderness and temperature 䊐 䊐 䊐 䊐 䊐
c. Masses: noting location, size in centimeters, shape, mobility, 䊐 䊐 䊐 䊐 䊐
consistency, and tenderness
d. Palpate nipples by compressing nipple gently between thumb 䊐 䊐 䊐 䊐 䊐
and index finger; observe for discharge
e. Palpate mastectomy site, if applicable, observing the scar and 䊐 䊐 䊐 䊐 䊐
any remaining breast or axillary tissue for redness, lesions,
lumps, swelling, or tenderness

Male Breasts

1. Inspect and palpate the breasts, areolas, and nipples for 䊐 䊐 䊐 䊐 䊐

swelling, nodules, or ulcerations.

Axillae

1. Inspect for rashes or infection. 䊐 䊐 䊐 䊐 䊐

2. Hold the elbow with one hand and use the three fingerpads 䊐 䊐 䊐 䊐 䊐
of your other hand to palpate firmly the axillary lymph nodes.

3. Palpate high into the axillae, moving downward against the ribs 䊐 䊐 䊐 䊐 䊐
to feel for the central nodes. Continue down the posterior axillae
to feel for the posterior nodes.

4. Use bimanual palpation to feel for the anterior axillary nodes. 䊐 䊐 䊐 䊐 䊐

5. Palpate down the inner aspect of the upper arm. 䊐 䊐 䊐 䊐 䊐
Analysis of Data

1. Formulate nursing diagnoses (wellness, risk, actual). 䊐 䊐 䊐 䊐 䊐

2. Formulate collaborative problems. 䊐 䊐 䊐 䊐 䊐
3. Make necessary referrals. 䊐 䊐 䊐 䊐 䊐

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138 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM

CHAPTER POSTTEST
Activity F MULTIPLE CHOICE
Choose the one best answer for each of the following multiple-choice questions.
1. After assessing the breasts of a female client, the nurse should explain to the client that most
breast tumors occur in the
a. upper inner quadrant.
b. lower inner quadrant.
c. upper outer quadrant.
d. lower outer quadrant.
2. A female client tells the nurse that her breasts become lumpy and sore before menstruation
but get better at the end of the menstrual cycle. The nurse should explain to the client that
these symptoms are often associated with
a. malignant tumors.
b. fibroadenoma.
c. fibrocystic breast disease.
d. increased estrogen production.
3. The nurse has discussed the risks for breast cancer with a group of high school seniors. The
nurse determines that one of the students needs further instructions when the student says
that one risk factor is
a. having a baby before the age of 20 years.
b. a family history of breast cancer.
c. consumption of a high-fat diet.
d. late menopause.
4. Cultural beliefs about the causes of breast cancer do not always agree with medical findings.
Hispanic Americans often associate breast cancer with
a. improper diet.
b. punishment from God.
c. physical stress.
d. evil thoughts.
5. The nurse is working with a community group to set up teaching programs to increase
awareness among African-American women about preventive screening techniques for breast
cancer. In the teaching program, the nurse should plan to include
a. local female physicians who work with cancer clients.
b. hospital clinic workers from various racial backgrounds.
c. nurses who work in outpatient centers.
d. breast cancer patients of the same race.
6. The nurse is caring for an adult female client when the client tells the nurse that she has had
a clear discharge from her nipples for the past month. The nurse should ask the client if she
has been taking
a. antidepressants.
b. antibiotics.
c. insulin.
d. contraceptives.

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 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM 139

7. The nurse is assessing an adult male client when the nurse observes gynecomastia in the
client. The nurse should ask the client if he is taking any medications for
a. inflammation.
b. depression.
c. infection.
d. ulcers.
8. The nurse is caring for a female client who has received a diagnosis of fibrocystic breast dis-
ease. The nurse has instructed the client about the disease. The nurse determines that the
client needs further instructions when the client says she should avoid drinking
a. regular coffee.
b. regular tea.
c. diet colas.
d. grapefruit juice.
9. The nurse plans to instruct an adult female client with regular menstrual cycles, who is not
taking oral contraceptives, about breast self-examination. The nurse should plan to instruct
the client to perform breast self-examination
a. during menstruation.
b. on the same day every month.
c. midway between the cycles.
d. right after menstruation.
10. The nurse observes an orange-peel appearance, or peau d’orange, of the areolae of a client’s
breasts. The nurse should explain to the client that this is most likely due to
a. blocked lymphatic drainage.
b. fibrocystic breast disease.
c. fibroadenomas.
d. radiation therapy.
11. The nurse is assessing a 50-year-old client’s breasts and observes a spontaneous discharge of
fluid from the left nipple. The nurse should
a. document this as a normal finding.
b. ask the client if she has had retracted nipples.
c. refer the client for a cytology examination.
d. determine whether the client wears a supportive bra.
12. The nurse observes dimpling in an adult female client’s breasts. The nurse should explain to
the client that dimpling of the breast may indicate a
a. fibroadenoma.
b. tumor.
c. genetic deviation.
d. fibrocystic breast.
13. The nurse is preparing to examine the breasts of a female client who had a left radical mas-
tectomy 3 years ago. When examining the client, the nurse observes redness at the scar area.
The nurse should explain to the client that this may be indicative of
a. additional tumors.
b. poor lymphatic drainage.
c. an infectious process.
d. metastasis to the right breast.

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140 CHAPTER 19 BREASTS AND LYMPHATIC SYSTEM

14. A client has had a recent mastectomy and visits the clinic for postoperative evaluation. The
client tells the nurse that she has been depressed and feels as if she is no longer a woman.
The most appropriate nursing diagnosis for this client is
a. ineffective individual coping related to mastectomy.
b. fear of additional breast cancer related to presence of risk factors.
c. PC: hematoma after mastectomy.
d. disturbed body image related to mastectomy.

Activity G MATCHING
Match the terms in the left column with the correct descriptions in the right column.
Term Description
1. Axillary lymph nodes a. Lymphatic obstruction, causing edema, which thickens
the skin, exaggerates the hair follicles, and gives the breast
2. Mammary gland
an orange-peel or pigskin look
3. Mastectomy b. Darkly pigmented area surrounding the nipple of the
4. Lactiferous duct mammary gland
c. Enlargement of one or both male breasts, seen more
5. Lactiferous sinus
frequently in adolescent boys and elderly men
6. Cooper’s ligaments d. Reservoirs for storing milk, located behind the nipple
7. Tail of Spence e. Pigmented projection at the tip of each breast, which
allows passage of milk from the breast
8. Areola
f. Specialized gland of the skin of females, which secretes
9. Nipple milk for nourishment of the young
10. Paget’s disease g. Roentgenography of the breast to detect any underlying
mass
11. Peau d’orange
h. Ducts conveying the milk secreted by the lobes of the
12. Mastitis breast to and through the nipples
13. Mammography i. Groups of lymph nodes located under the arm (the axilla)
14. Gynecomastia j. Inflammation of the breast
k. Cone-shaped breast tissue that projects up into the axillae
l. Surgical removal of breast tissue
m. Fibrous glands extending vertically from the breast surface
to attach on the chest wall muscles
n. Erythematous scaling lesion of the breast, involving the
nipple and areola unilaterally, and associated with an
underlying malignancy

Activity H CRITICAL THINKING AND CASE STUDIES

1. Read the following case study and analyze the client’s risk factors for the development of breast cancer.
Julia Hershey is a 67-year-old retired secretary. Her mother and a sister have been treated for breast
cancer, but Ms. Hershey has no personal history of cancer. She gave birth to her only child when
she was 37 years of age. She states that her daughter was a “bottle baby” and that breast-feeding
was not “proper” back when her daughter was a baby. Ms. Hershey states that she went through
the “change” (menopause) in her late 40s. Although she understands how to perform breast self-
examinations, Ms. Hershey states that she does not do them on a regular basis. Her chart indicates
that her last mammogram was 6 years ago.

Copyright © 2010. Lippincott Williams and Wilkins.