Page 381 - Saunders Comprehensive Review For NCLEX-RN

(Box 12-10).
8. Refer to Chapter 52 for diagnostic tests related to the
cardiovascular system.

9. Client teaching

a. Advise client to modify lifestyle for risk
factors associated with heart and
vascular disease.
b. Encourage the client to seek regular
physical examinations.
c. Client should seek medical assistance
for signs of heart or vascular disease.
H. Breasts
1. Subjective data: Pain or tenderness, lumps or

thickening, swollen axillary lymph nodes, nipple
discharge, rash or swelling, medications being taken,
personal or family history of breast disease, trauma or
injury to the breasts, previous surgery on the breasts,
breast self-examination (BSE) compliance,
mammograms as prescribed

2. Objective data: Inspection and palpation

3. Inspection
a. Performed with the client’s arms raised
above the head, the hands pressed
against the hips, and the arms
extended straight ahead while the
client sits and leans forward
b. Assess size and symmetry (1 breast is
often larger than the other); masses,
flattening, retraction, or dimpling;
color and venous pattern; size, color,
shape, and discharge in the nipple and
areola; and the direction in which
nipples point.
4. Palpation
a. Client lies supine, with the arm on the
side being examined behind the head
and a small pillow under the shoulder.
b. The nurse uses the pads of the first 3
fingers to compress the breast tissue
gently against the chest wall, noting
tissue consistency.
c. Palpation is performed systematically,
ensuring that the entire breast and tail
are palpated.

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