. A woman who presents with dimpling of the right breast states that it occurred in the last two weeks. She has not performed a breast self-examination. What assessment should the nurse make?
A) Evaluate the patient's milk production
B) Palpate the area for a breast mass
C) Order an immediate mammogram
D) Call the physician to schedule a biopsy
Ans: B
Feedback: It would be most important for the nurse to palpate the breast to determine the presence of a mass. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage, giving the skin an orange-peel appearance (peau d'orange), a classic sign of advanced breast cancer. Evaluation of milk production is required in lactating women, but there is no indication of lactation in the scenario. A mammogram is an appropriate diagnostic test, but unless the nurse is a practitioner this would not be within her realm of practice. A referral could be made to a physician but the nurse would not proceed to schedule a biopsy.
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