114 chp 22 ex 2

A client tells a nurse that she has been experiencing intermittent episodes of numbness, tingling, pain, and burning in the fingertips, especially after being cold. What is an appropriate question for the nurse to ask the client to further assess this occurrence?

"Do you notice your fingers changing colors?"

A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?

"The area of cramping is close to the area of arterial occlusion."

Which statement made by a student nurse concerning how to test a client for a paradoxical pulse would indicate that the nurse needs further education?

"The difference between the pressures at the two levels is normally no greater than 5 mm Hg."

The ABI is calculated by dividing the systolic BP at the dorsalis pedis by the systolic BP at the brachial artery. Which of the following values would be consistent with mild peripheral arterial disease?

0.85

A client presents with pitting edema to the left foot, which a nurse observes as slight pitting when the area is depressed. How should the nurse accurately document this amount of edema?

1+

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person?

1.00

A client presents with pitting edema to the left foot, which a nurse observes as a noticeably deep pit when the area is depressed and the extremity looks larger than the right. How should the nurse accurately document this amount of edema?

3+

A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record?

4+

The nurse encourages a client to perform a monthly self-breast examination between what days of the menstrual cycle?

4-7 right after menstr

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

5

Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body's blood volume that is contained in the veins is nearly

70

Which of the following wounds is most likely attributable to neuropathy?

A painful wound in the client's shin, which is surrounded by apparently healthy skin

Which of the following wounds is most likely attributable to neuropathy?

A painless wound on the sole of the client's foot, which is surrounded by calloused skin

A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?

Abdomen, noting any organ enlargement or tenderness

After a physical examination of the peripheral and vascular systems, the nurse determines that a client is at risk for the development of venous disease. What teaching would be appropriate for this client? (Select all that apply.)

Achieve a normal body weight. Drink an adequate amount of fluids. Avoid prolonged sitting and standing. Participate in daily exercise.

Which description of exterior landmarks indicates normal positioning of the lungs?

Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line.

During an assessment, the nurse first performs the action shown. After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

Arterial insufficiency

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?

Arterial occlusion

The nurse is assessing a client's readiness to quit smoking. Place in order the steps in which the nurse will conduct this assessment.

Ask about tobacco use Advise to quit Assess willingness to quit Assist to quit Arrange follow-up

A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse?

Ask the client to assume the left lateral position

Which of the following interventions can the nurse use to help a client modify risk factors associated with hypertension? (Select all that apply).

Ask the client to keep a "typical day" record of daily food intake Ask the client to keep an activity log Provide information about aids to promote smoking cessation

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding?

Assess adequacy of blood flow using a Doppler device.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible.

The nurse instructs the client to lean forward so she can inspect the breasts. What might this position reveal that is not visible in another position?

Asymmetry of the breast or nipple

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

Capillary refill greater than 2 seconds

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?

Check feet daily for cuts or pressure areas.

Describe the chest pain symptoms for a patient that has a myocardial infarction

Chest pain is not affected with respirations

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?

Cheyne-Stokes

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

Cigarette smoking Previous use of hormones High-fat diet

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find?

Cold fingers and hands

The nurse is suspicious of a deep vein thrombosis (DVT) in a client's right calf area. Which actions should the nurse perform or assist with to aid in the diagnosis of DVT? (Select all that apply.)

Complete Wells Score System Draw lab work for D-dimer Prepare client for venous duplex scan Measure calf size in both legs

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

Cool skin

In assessing a client, a nurse palpates her epitrochlear lymph nodes and notes that the client may have an infection in the hand or forearm. The nurse understands that which of the following are functions of the lymphatic system? Select all that apply.

Drains excess fluid and plasma proteins from tissues and returns them to the venous system Traps and destroys microorganisms and foreign materials filtered from lymph Absorbs fats from the small intestine into the bloodstream

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action?

Elevate the legs on pillows.

A nurse performs the Allen test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test?

Ensure that the client's hand is not opened in exaggerated extension

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

Firmly compress the lower portion of the varicose vein

A client comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the client asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response?

Fluid overload from elevation of the legs

A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?

History of breast surgery

What is the Virchow triad? (Mark all that apply.)

Hypercoagulability Vessel wall damage Venous stasis

The nurse notes that a client's lower left leg swelling is alleviated when the extremity is elevated. Which stage of lymphedema is this client experiencing?

I

The nurse is planning care for a client recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

Immobility

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

Impaired Gas Exchange

A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral arterial disease. Which of the following is a common symptom that could indicate peripheral arterial disease?

Intermittent claudication

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what?

Intermittent claudication

The nurse selects teaching material after completing a client's examination of the breasts and axillae. Why did the nurse provide the client with the diagram shown?

It demonstrates the location of breast cysts

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?

Legs should be elevated for 15 seconds

A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next?

Lightly palpate the client's leg veins for tenderness

A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?

Lower arm and hand for erythema and swelling

Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results?

Make sure the temperature in the room is comfortable.

A nurse inspects the lower extremities of a client and notices that the legs appear asymmetric. What should the nurse do first in regards to this finding?

Measure the diameter of the calves

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Notify the healthcare provider.

A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency?

Pallor of foot occurs with elevation

A nurse palpates a weak left radial artery on a client. What should the nurse do next?

Palpate both radial arteries for symmetry.

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

Peripheral vascular problems

What is a function of the lymph system?

Produce antibodies

The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?

Quitting smoking and keeping good control of your blood sugar levels are important.

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia?

Sinus arrhythmia

A person with a barrel chest has a problem doing what?

Taking a deep breath

A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?

The time from firing of the sinoatrial (SA)node to the beginning of depolarization in the ventricle

The nurse instructs a female client on breast self-examination. Which part of the breast should the nurse explain as being the area where most cancers occur?

The upper outer quadrant is the area most targeted by breast cancer.not tail of spence

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?

There is loss of involuntary respiratory control.

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

Thin, shiny, atrophic skin

The nurse is preparing discharge teaching for a client diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include?

To avoid sitting for long periods

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?

Trendelenburg test

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?

Venous insufficiency

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely?

Venous insufficiency

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?

Venous thromboembolism

When you enter the room of a hospitalized client, you note that the client is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?

Venous thromboembolism

A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?

Warm skin and brown pigmentation around the ankles

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition?

abi

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?

allen test

What is a long-term complication of peripheral vascular disease?

amputation

While assessing the legs of the client, the nurse notes that the legs and feet are cool to the touch. What would the nurse know is most often the cause of bilateral coolness?

anxiety

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing

arterial insufficiency.

Which activities are focused on the assessment of chronic venous insufficiency of the lower extremities? Select all that apply.

assessing for brownish pigmentation of the skin assessing for pitting edema assessing for a history of incompetent venous system valves

When assessing temperature of the skin, which portion of the hand should the examiner use?

backs of fingers

The largest arteries of the upper extremities are the

brachial arteries

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's

brachial pulse.

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

brisk, expected (normal) pulse

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.

bronchial

The nurse is assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the client's pain be most concerning?

calf

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the

competence of the saphenous vein valves.

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?

daibetes

On questioning a client with peripheral edema during an interview, the nurse learns that the client has a sedentary job and drinks little water throughout the day. What underlying condition is the client most likely to have, based on these findings?

dvt

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

dvt

Walking contracts the calf muscles and forces blood away from the heart.

f

The nurse is unable to palpate a client's left popliteal artery. Which artery should be assessed to determine the presence of blood flow in the left leg?

femoral

The nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. The nurse should instruct the client to

flex elbow 90 degrees

Which nursing assessment findings support a medical diagnosis of acute lymphangitis? Select all that apply.

history of animal bite red streak noted on skin fever is present

A 77-year-old retired nurse has an ulcer on a lower extremity. All the following diseases are responsible for causing ulcers in the lower extremities except for:

htn

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?

less than 90 degrees

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with

malignancy

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?

pad

When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause?

pad

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

pleurisy

After assessing pitting edema below the knee in a client, the nurse would suspect that which artery may be occluded?

popliteal

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

psterior tibial

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

r cerv node

The nurse is assessing a 50-year-old client's breasts and observes a spontaneous discharge of fluid from the left nipple. The nurse should

refer the client for a cytology examination.

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

repeat the phrase "ninety-nine."

The nurse notes that a client's heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding?

sinus arrhythmia

A nurse should ask a client to assume which position to begin the examination of the breasts?

sit

Which accessory muscles are most important when considering inspiratory breathing needs during exercise?

sternocleidomastoid

The radial pulse is palpated over the lateral flexor surface.

t

Which vessels return the lymph fluid to circulation?

thoracic ducts

The nurse instructs a female client on breast self-examination. Which part of the breast should the nurse explain as being the area where most cancers occur

upper outer

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

upper torso Head Upper extremities

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

venous insufficiency

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

venous insufficiency.

The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction (MI). What would the nurse expect to hear when auscultating the client's heart sounds?

wide splitting