During an assessment, a female patient asks why the nurse is "feeling her armpit.". Which responses are appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. "I'm counting your ribs.".
2. "Don't you feel your own armpits?"
3. "Breast tissue extends into this area.".
4. "I'm assessing hair distribution in this area.".
5. "The armpits should be part of your breast self-exam.".
3,5
Rationale 1: Counting the ribs is unnecessary.
Rationale 2: This response does not address the patient's question.
Rationale 3: Various palpation patterns may be used as long as every part of each breast is palpated, including the axillary tail, or the tail of Spence, which is the breast tissue that extends from the upper outer quadrant toward and into the axillae.
Rationale 4: Hair distribution would be assessed with visualization, not palpation.
Rationale 5: The nurse will explain breast self-exam (BSE) to the patient.
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