Chapter 21: Peripheral Vascular System and Lymphatic System

Which of the following statements best describes the mechanism(s) by which venous blood returns to the heart? 1. Intraluminal valves ensure unidirectional flow toward the heart. 2. Contracting skeletal muscles milk blood distally toward the veins. 3. The high-pressure system of the heart helps to facilitate venous return. 4. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: 1 Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow.

How would the nurse document mild, slight pitting edema present at the ankles of a pregnant patient? 1. 1+/0-4+ 2. 3+/0-4+ 3. 4+/0-4+ 4. Edema present

ANS: 1 If pitting edema is present, grade it on a scale of 1+ (mild) to 4+ (severe).

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. This patient is most likely experiencing: 1. claudication. 2. sore muscles. 3. muscle cramps. 4. venous insufficiency.

ANS: 1 Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes.

When assessing a patient the nurse documents the left femoral pulse as 0/0-4+. Which of the following findings would the nurse expect at the dorsalis pedis pulse? 1. 0/0-4+ 2. 1+/0-4+ 3. 2+/0-4+ 4. 3+/0-4+

ANS: 1 Pulsations are graded on a four-point scale: 0, absent; 1+, weak; 2+, normal; 3+, increased; 4+, bounding. If a pulse is absent at the femoral site, one would expect the dorsalis pedis pulse to be absent also.

A patient has hard, nonpitting edema of the left lower leg and ankle. The nurse knows that: 1. nonpitting, hard edema occurs with lymphatic obstruction. 2. alterations in arterial function will cause this edema. 3. phlebitis of a superficial vein will cause bilateral edema. 4. long-standing arterial obstruction will cause pitting edema.

ANS: 1 Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, it is nonpitting and feels hard to the touch.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include: Select all that apply. 1. Intense, sharp pain, with the deep muscle tender to touch 2. Aching, tired pain, with a feeling of fullness 3. Pain is worse at the end of the day. 4. Onset is sudden. 5. Calf is warm, red, and swollen. 6. Pain is relieved with elevation of leg.

ANS: 1, 4, 5 Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. Options 2, 3, and 6 are symptoms of chronic venous problems.

Which of the following situations best describes a person at risk for development of venous disease? 1. A woman in her fifth month of pregnancy 2. A person who has been on bed rest for 4 days 3. A person with a 30-year, 1 pack per day smoking history 4. An elderly person taking anticoagulant medication

ANS: 2 At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable states and vein wall trauma also place the person at risk for venous disease.

A patient has a positive Homan's sign. The nurse knows that a positive Homan's sign: 1. occurs with venous insufficiency. 2. is indicative of possible thrombophlebitis. 3. is seen in the presence of severe edema. 4. indicates problems with arterial circulation.

ANS: 2 Calf pain on dorsiflexion of the foot is a positive Homan's sign, which occurs in about 35% of deep vein thrombosis. It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury.

During an assessment, the nurse notes that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting edema. The right arm is normal. The patient had a mastectomy 1 year ago. The nurse suspects which problem? 1. Venous stasis 2. Lymphedema 3. Arteriosclerosis 4. Deep vein thrombosis

ANS: 2 Chronic lymphedema is unilateral swelling, nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer and can impede drainage of lymph.

During an assessment, the nurse has elevated a patient's legs 12 inches off the table and has had him wiggle his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse would expect a normal finding at this point would be: 1. marked elevational pallor. 2. venous filling within 15 seconds. 3. pain in the feet and lower legs when assuming a sitting position. 4. color returning to the feet within 20 seconds of assuming a sitting position.

ANS: 2 In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill.

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding would the nurse expect to note? 1. Excessive swelling of the lymph nodes 2. The presence of palpable lymph nodes 3. No nodes palpable because of the immature immune system of a child 4. Fewer numbers and a decrease in size of lymph nodes compared with those of an adult

ANS: 2 Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated, which disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the patient is most likely experiencing: 1. pain related to lymphatic abnormalities. 2. problems related to arterial insufficiency. 3. problems related to venous insufficiency. 4. pain related to musculoskeletal abnormalities.

ANS: 2 Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: 1. lymphedema. 2. Raynaud's syndrome. 3. deep vein thrombosis. 4. chronic arterial insufficiency.

ANS: 2 The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud's syndrome.

Which of the following statements regarding the lymphatic system is true? 1. Lymph flow is propelled by the contraction of the heart. 2. The flow of lymph is slow compared with that of the blood. 3. One of the functions of the lymph is to absorb lipids from the biliary tract. 4. Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream and back again.

ANS: 2 The flow of lymph is slow compared with that of the blood.

A 35-year-old man is seen in the clinic for an "infection in my left foot." Which of the following would the nurse expect to find during an assessment of this patient? 1. Hard and fixed cervical nodes 2. Enlarged and tender inguinal nodes 3. Bilateral enlargement of the popliteal nodes 4. "Pellet-like" nodes in the supraclavicular region

ANS: 2 The inguinal nodes in the groin drain most of the lymph of the lower extremity. With local inflammation, the nodes in that area become swollen and tender.

Which of the following statements is true regarding the arterial system? 1. Arteries are large-diameter vessels. 2. The arterial system is a high-pressure system. 3. The walls of arteries are thinner than those of veins. 4. Arteries can expand greatly to accommodate a large blood volume increase.

ANS: 2 The pumping heart makes the arterial system a high-pressure system.

The nurse is attempting to assess the femoral pulse in an obese patient. Which of the following actions would be most appropriate? 1. Have the patient assume a prone position. 2. Ask the patient to bend his or her knees to the side in a frog like position. 3. Press firmly against the bone with the patient in a semi-Fowler's position. 4. Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse.

ANS: 2 To help expose the femoral area, particularly in obese people, ask the person to bend his or her knees to the side in a frog like position.

The nurse uses the "profile sign" to detect: 1. pitting edema. 2. early clubbing. 3. symmetry of the fingers. 4. insufficient capillary refill.

ANS: 2 Use the profile sign (viewing the finger from the side) to detect early clubbing.

The nurse is reviewing an assessment of a patient's peripheral pulses and notes that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? 1. Bounding 2. Normal 3. Weak 4. Absent

ANS: 2 When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

Which of the following pulses would most likely be seen in an individual with untreated hyperthyroidism? 1. A normal pulse 2. An absent pulse 3. A bounding pulse 4. A weak, thready pulse

ANS: 3 A full, bounding pulse occurs with hyperkinetic states such as exercise, anxiety, fever, anemia, and hyperthyroidism.

The nurse would perform a modified Allen test for which reason? 1. To measure the rate of lymphatic drainage 2. To evaluate the adequacy of capillary patency before venous blood draws 3. To evaluate the adequacy of collateral circulation before cannulating the radial artery 4. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

ANS: 3 A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated.

When describing a weak, thready pulse, the nurse should document: 1. "Easily palpable, pounds under the fingertips." 2. "Greater than normal force, then collapses suddenly." 3. "Hard to palpate, may fade in and out, easily obliterated by pressure." 4. "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

ANS: 3 A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse will assess for other signs and symptoms of: 1. varicosities. 2. a venous stasis ulcer. 3. an arterial ischemic ulcer. 4. pitting edema.

ANS: 3 Arterial ischemic ulcers occur at toes, metatarsal heads, heels, and lateral ankle, and are characterized by pale ischemic base, well-defined edges, and no bleeding.

A patient has bilateral pitting edema of the feet. In the assessment of the peripheral vascular system, the nurse's primary focus should be: 1. oxygenation of the lower extremities. 2. arterial function of the lower extremities. 3. venous function of the lower extremities. 4. possible thrombophlebitis of the lower extremities.

ANS: 3 Bilateral pitting edema of the lower extremities occurs with heart failure, venous disease, or lymphatic obstruction.

The nurse is performing a peripheral vascular assessment on a bedridden patient, and notes the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan's sign. The nurse would: 1. reevaluate the patient in a few hours. 2. consider this a normal finding for a bedridden patient. 3. seek emergency referral because of the risk of pulmonary embolism. 4. ask the patient to raise his leg off of the bed and check for pain on elevation.

ANS: 3 Increased warmth, swelling, redness, and tenderness require emergency referral because of the risk of pulmonary embolism.

A 65-year-old patient is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with: 1. venous obstruction of the left leg. 2. claudication due to venous abnormalities in the left leg. 3. ischemia caused by partial blockage of an artery supplying the left leg. 4. ischemia caused by complete blockage of an artery supplying the left leg.

ANS: 3 Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only at exercise, when oxygen needs increase.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse would next: 1. check for the presence of claudication. 2. refer the individual for further evaluation. 3. consider this a normal finding and proceed with the peripheral vascular evaluation. 4. ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

ANS: 3 It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable.

The nurse is performing a well-child assessment on a 3-year-old child. The child's vital signs are normal. Capillary refill time is 5 seconds. The nurse would: 1. ask the parent if the child has had frostbite in the past. 2. suspect that the child has a venous insufficiency problem. 3. consider this a delayed capillary refill time and investigate further. 4. consider this a normal capillary refill time that requires no further assessment.

ANS: 3 Normal capillary refill time is less than 1 to 2 seconds. Note that these conditions can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His past medical history is unremarkable, and he received immunizations 1 week ago. Which of the following findings would be considered normal in this situation? 1. Enlarged, warm, tender nodes 2. Lymphadenopathy of the cervical nodes 3. Palpable firm, small, shotty, mobile, nontender lymph nodes 4. Firm, rubbery, large nodes, somewhat fixed to the underlying tissue

ANS: 3 Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.

The nurse recognizes that which of the following is a normal physiologic change associated with the aging process? 1. Hormonal changes causing vasodilation and a resulting drop in blood pressure. 2. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. 3. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. 4. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities.

ANS: 3 Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure.

The major artery supplying the arm is the: 1. ulnar artery. 2. radial artery. 3. brachial artery. 4. deep palmar artery.

ANS: 3 The major artery supplying the arm is the brachial artery.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard 1. A low humming sound 2. A regular "lub, dub" pattern 3. A swishing, whooshing sound 4. A steady, even, flowing sound

ANS: 3 When using the Doppler ultrasonic stethoscope, the pulse site is noted when one hears a swishing, whooshing sound.

Which of the following is a true statement regarding the manual compression test? 1. Rapid filling of the veins indicates incompetent veins. 2. Competent valves in the veins will transmit a wave to the distal fingers. 3. A palpable wave transmission occurs when the valves are incompetent. 4. The test assesses whether the valves of varicosity are competent when the person is in the supine position.

ANS: 3 With the manual compression test, a palpable wave transmission occurs when the valves are incompetent.

A patient has been diagnosed with venous stasis. Which of the following would the nurse most likely observe? 1. A unilateral cool foot 2. Thin, shiny, atrophic skin 3. Pallor of the toes and cyanosis of the nailbeds 4. A brownish discoloration to the skin of the lower leg

ANS: 4 A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a byproduct of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

When auscultating over a patient's femoral arteries the nurse notes the presence of a bruit on the left side. The nurse knows that: 1. bruits are often associated with venous disease. 2. bruits occur in the presence of lymphadenopathy. 3. hypermetabolic states will cause bruits in the femoral arteries. 4. bruits occur with turbulent blood flow, indicating partial occlusion.

ANS: 4 A bruit occurs with turbulent blood flow, indicating partial occlusion of the artery.

A 70-year-old patient is scheduled for open-heart surgery. The physicians plan to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: 1. "Venous insufficiency is a common problem after this type of surgery." 2. "Oh, we have lots of veins—you won't even notice that it has been removed." 3. "You will probably experience decreased circulation after the veins are removed." 4. "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

ANS: 4 As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation.

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing: 1. pulsus alternans. 2. pulsus bisferiens. 3. pulsus bigeminus. 4. pulsus paradoxus.

ANS: 4 In pulsus paradoxus, beats have a weaker amplitude with inspiration, stronger with expiration. It is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

To assess the dorsalis pedis artery, the nurse would palpate: 1. behind the knee. 2. over the lateral malleolus. 3. in the groove behind the medial malleolus. 4. lateral to the extensor tendon of the great toe.

ANS: 4 The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.

When performing an assessment of a patient, the nurse notes the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? 1. Assess the patient's abdomen, noting any tenderness. 2. Carefully assess the cervical lymph nodes, checking for any enlargement. 3. Ask additional history questions regarding any recent ear infections or sore throats. 4. Examine the patient's lower arm and hand, checking for the presence of infection or lesions.

ANS: 4 The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm.

Which of the following veins are responsible for most of the venous return in the arm? 1. Deep veins 2. Ulnar veins 3. Subclavian veins 4. Superficial veins

ANS: 4 The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

Which of the following statements is true regarding assessment of the ankle- brachial index (ABI)? 1. Normal ABI indices are from 0.50 to 1.0. 2. The normal ankle pressure is slightly lower than the brachial pressure. 3. The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals. 4. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication.

ANS: 4 Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication.