After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)
a. Peau d'orange
b. Dense breast tissue
c. Nipple retraction
d. Mobile mass at two o'clock
e. Nontender axillary nodes
ANS: A, C, D
In the documentation of a breast mass, skin changes such as dimpling (peau d'orange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the "face of a clock." Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer.
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