During the focused assessment of a female client, she reports breast tenderness, swelling, and lymph node enlargement around the time of her period. The nurse's best response to this finding is:
1. "This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly.".
2. "Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider.".
3. "As long as you have not detected any lumps you have nothing to worry about.".
4. "Do you have a history of fibrocystic breast disease? These symptoms are usually seen with this disease.".
2
Rationale 1: Nodularity is a benign physiologic condition of lumps in the breasts that occur just prior to the menstrual period through the end of the period. The client in this scenario does not report any lumps.
Rationale 2: Fluctuating hormone levels frequently cause these symptoms, along with breast pain. Contraceptives can also cause these symptoms. The nurse is also correct in documenting the symptoms and informing the primary care provider so that further evaluation can occur.
Rationale 3: "As long as you have not detected any lumps you have nothing to worry about," does not validate the information the client is reporting, nor does it help to tell the client not to worry. In addition, this response may lead the client to believe that only lumps would be of significance to report.
Rationale 4: While fibrocystic breast disease frequently coincides with fluctuating hormone levels of menstruation, its symptoms vary in that along with painful breasts, the client will have masses upon palpation that feel soft, well demarcated, and freely movable. These masses are usually found bilaterally. Clear, straw colored, milky, or green discharge from the nipples may also occur.
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