NR 509 FINAL EXAM QUESTIONS AND ANSWERS 2022

NR 509 FINAL EXAM QUESTIONS AND ANSWERS 2022

CHAPTER 18: BREASTS AND AXILLAE

• A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right

breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider.After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group?

• BSE is well evidenced, and all recommending agencies agree that it should be taught and

reinforced.

• Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual

examinations starting at age 30 years.

• This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF)

recommendations for her age group and risk factors prior to her current complaint.

• Mammography is most sensitive and specific for women in their 40s, when breast tissue is

still dense enough to image accurately.

• Breast cancer screening is extremely well studied, and no controversy exists on the

recommended norms for screening and follow-up.

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• A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge.

This discharge started several weeks ago and has occurred at irregular intervals since that time.She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis?

• Mastitis
• Ductal carcinoma in situ
• Paget disease of the breast
• Occult pregnancy
• Prolactinoma

• A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on

breast self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self-detection of breast cancer?

• Most masses that women find at home and bring to a provider’s attention turn out to be

malignant.

• This patient is more likely to find a fibroadenoma than a cancer on self-examination.
• The most likely breast mass this patient is likely to find in herself is an abscess complicating

underlying mastitis.

• Because of this patient’s age, breast masses should not be pursued with imaging and

diagnosis because the risk of cancer is so low.

• BSE is universally recommended because of very high sensitivity and specificity for finding

cancerous lesions.

• A 48-year-old female psychologist presents to clinic with concerns about her breast cancer

risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father’s side in as many years to be diagnosed with breast cancer, including the patient’s own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient’s indications for BRCA testing? 2 / 4

• Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in

assessing her risk for these genes.

• Breast cancer in a male relative does not add significant weight to the decision to test for the

BRCA genes in this patient.

• The BRCAPRO calculator does not add any further clinical information to this patient’s risk for

carrying the BRCA gene.

• This patient carries several risk factors that together justify BRCA testing.
• Even if this patient is BRCA positive, no changes in screening or treatment are recommended

for patients with this genetic mutation, so the test is not recommended.

• A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer

risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient?

• No agency recommends breast MRI for a patient such as this one, who has moderately but

not extraordinary risk factors for breast cancer.

• The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for

patients with such risk factors.

• Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of

markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts).

• Mammograms are not affected by breast density and thus density is not a factor in choosing

MRIs over mammograms in patients such as this individual.

• History of chest radiation is not a risk factor for breast cancer and is thus not relevant to

deciding whether MRI is appropriate in this patient.

• A 66-year-old female museum curator presents for a routine annual examination. On

examination, a notably enlarged supraclavicular lymph node is appreciated on the right side.The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy? 3 / 4

• Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the

breast uniformly drain into the axilla.

• Supraclavicular nodes are generally considered benign and require no further evaluation or

follow-up.

• Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.
• Firm, rubbery lymph nodes are generally considered to be benign.
• Metastatic breast cancer cells may spread directly into the infraclavicular and then

supraclavicular nodes without first causing notable changes in the axillary nodes.

• A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery,

mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a firbroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report this finding?

• “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the

nipple”

• “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
• “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
• “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”
• “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the

nipple”

• A 54-year-old female dietician presents for a routine annual examination. On review of

systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause?

• Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity

and specificity of mammograms.

• Estrogen in hormone replacement therapy (HRT) has no effect on breast density after

menopause.

• Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the

number of lobules.

• Breast density has no genetic component and is entirely due to estrogen dose from

endogenous and exogenous sources over the lifetime.

• Mammography performs most poorly in the menopausal and postmenopausal age group and

should be limited for that reason.

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