Page 382 - Saunders Comprehensive Review For NCLEX-RN

d. The nurse notes the consistency of the
breast tissue, which normally feels
dense, firm, and elastic.
e. The nurse gently palpates the nipple
and areola and compresses the nipple,
noting any discharge.
f. It is important to document lump or
mass characteristics, which includes
size, shape, consistency, movability,
distinctness, nipple characteristics,
skin findings over the lump,
tenderness, and lymphadenopathy.
5. Axillary lymph nodes
a. The nurse faces the client and stands on
the side being examined, supporting
the client’s arm in a slightly flexed
position, and abducts the arm away
from the chest wall.
b. The nurse places the free hand against
the client’s chest wall and high in the
axillary hollow, then, with the
fingertips, gently presses down, rolling
soft tissue over the surface of the ribs
and muscles.
c. Lymph nodes are normally not
palpable.

6. Client teaching

a. Encourage and teach the client to
perform BSE (refer to Chapter 44 for
information on performing BSE).
b. Client should report lumps or masses to
the PHCP immediately.
c. Regular physical examinations and
mammograms should be obtained as
prescribed.
I. Abdomen

1. Subjective data: Changes in appetite or weight,

difficulty swallowing, dietary intake, intolerance to
certain foods, nausea or vomiting, pain, bowel habits,
medications currently being taken, history of
abdominal problems or abdominal surgery

2. Objective data

a. Ask the client to empty the bladder.
b. Be sure to warm the hands and the

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