220 chapter 20
slight 2mm depression ___ edema
1+
increased 4mm depression ___ edema
2+
deeper pitting edema 6 mm depression ____ edema
3+
severe pitting edema 8mm depression ___ edema
4+
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 vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system? A) intermittent claudication B) chest pressure with exertion C) SOB D) knee pain
A
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? A) do you notice your fingers changing colors? B) do you have a history of cardiovascular disease C) have you started any new medications D) are you exercising when this occurs?
A
A finding on palpation that suggests venous insufficiency is A) diminished dorsalis pedis pulse in an edematous foot B) diminished sensations of dorsum of right foot C) ulcerations on toes of left foot D) cool lower legs and feet
A
A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) upper arm B) posterior neck C) axillary area D) inguinal area
A
A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding? A) pain in the calf muscle B) tenderness on plantar flexion C) cramping pain in both thighs D) pallor of leg on elevation
A
A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency A) deep ulcers that often involve joint space B) ulcer commonly located in anterior tibial area C) painful ulcer with irregular border D) moderate to severe leg edema
A
A patient is admitted with leg ulcers to the HCF. During collection of objective data which assessment finding should indicate to the nurse that the clients leg ulcers are due to arterial insufficiency A) pallor of foot occurs with elevation B) reports of aching, cramping pain C) irregular-shaped ulcer on inner aspect of ankle D) ulcer located on medial malleolus
A
Assessment of a patients radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? A) 3+ B) 1+ C) 2+ D) 4+
A
During the physical assessment of the peripheral vascular system, a patient's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this patient is at risk for developing: A) arterial insufficiency ulcers B) venous insufficiency ulcers C) neuropathic ulcers D) DVT
A
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? A) calf B) knee C) thigh D) ankle
A
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? A) venous insufficiency B) arterial insufficiency C) neuropathic ulcer D) trauma
A
The pressure wave of a patient's brachial pulse is bounding. What does this assessment finding suggest to the nurse A) normal aging B) aortic stenosis C) left-sided heart failure D) obstructive lung disease
A
Which area of the arm drains to the epitrochlear nodes? A) ulnar surface of forearm and hand little and ring fingers, and ulnar middle finger B) radial surface of forearm and hand, second third, and fourth finger C) ulnar surface of hand, second third and fourth finger
A
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? A) thin, shiny, atrophic skin B) makred edema C) normal temp D) normal pulsation
A
What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply A) intraluminal valves B) respiration C) cardiac output D) skeletal muscle contraction E) activity level
A, B, D
After a physical examination of the peripheral and vascular systems, the nurse determines that a patient is at risk for the development of venous disease. What teaching would be appropriate for this patient? (Select all that apply.) A) participate in daily exercise B) drink an adequate amount of fluids C) limit alcohol intake D) avoid prolonged sitting and standing E) achieve a normal body weight
A, B, D, E
(select all that apply) The nurse is preparing to conduct a peripheral vascular and lymphatic physical examination of a patients legs. What should the nurse instruct the patient to prepare for this exam? A) assist to a lying position on a bed or exam table B) instruct to remove clothing below the waist C) assist to a standing position at the foot of the bed or exam table D) instruct to remove all clothing E) instruct that the prone position may be needed to assess some pulses
A, B, E
(Select all that apply) the nurse explains to the patient with a diagnosis of peripheral vascular disease her is is at risk for what occuring? A) stroke B) obesity C) hypertension D) myocardial infarction E) diabetes
A, D
(select all that apply) while inspecting the lower extremities of a patient the nurse observes an ulcer. WHich of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency A) circular shape B) moderate leg edema C) irregular border D) client reports of severe pain E) deep
A, D, E
Symptoms of complete arterial occlusion include which of the following? Select all that apply. A) color change B) erythema C) heat D) pain E) numbness
A, D, E
A nurse experiences difficulty in palpating the popliteal pulses in a client during assessment of the peripheral vascular system. What should the nurse do to assist in locating this pulse on a client? A) lower the leg so that it dangles off the bed B) place the client in the prone position C) have the client cross the legs with the knee bent D) warm the legs to prevent vasoconstriction
B
A nurse is having difficulty palpating the femoral pulse on a adult patient. which of the following would be most appropriate for the nurse to do ? A) perform the allens test? B) listen for femoral bruits C) ask another nurse to assess the pulse D) assess the popliteal pulse
B
A nurse performs the Allen's 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? A) keep both arteries occluded and have patient release the fist B) ensure the clients hand is not opened in exaggerated extension C) have patient rest hand palm side up and make a fist
B
A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency? A) moderate to severe leg edema B) deep ulcers that often involve joint spaces C) ulcer commonly located in anterior tibial area D) painful ulcer with irregular border
B
An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect? A) neurologic impairment B) arterial insufficiency C) venous insufficiency D) musculoskeletal weakness
B
aortic aneurysms are seen with which congenital disorder? A) chronic lymphadenopathy B) Marfan's syndrome C) peripheral artery disease D) Raynaud's disease
B
before begining the assessment of the vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results A) ensure proper lighting in the room B) make sure the temp in the room is comfortable C) place the patient in a position of comfort for the entire exam D) allow patient to empty bladder
B
older adults tend to get arteriosclerosis. what is the cause of this disease process A) high-fat diet B) calcification of the arteries C) plaque buildup in the arteries D) low LDL
B
While completing the past history of a patient's peripheral vascular and lymphatic systems, the nurse is concerned that the patient is at risk for peripheral vascular disorders. What did the nurse assess in this patient? (Select all that apply.) A) BP 178/90 B) currently smokes 1 pack/day C) BMI 30 D) mother diagnosed with diabetes at age 70 E) heart attack 5 years ago
B, C
(select all that apply) A patient with hypertension is at increased risk of what medical conditions? A) varicose veins B) cerebrovascular disease C) lower-extremity peripheral artery disease D) deep vein thrombosis E) abdominal aneurysms
B, C, E
A client presents with pitting edema to the left foot, which the 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 A) 1+ B) 4+ C)3+ D) 2+
C
A nurse assesses a patients epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next? A) assess both legs for homan's sign B) ask the patient about any recent ear and throat infections C) examine the lower arm and hand for infection sites D) carefully assess the cervical lymph nodes for enlargement
C
A nurse inspects the lower extremities of a client and notices that the legs appear asymmetrical. What should the nurse do first in regards to this finding A) notify the HCP B) assess for the presence of pitting edema C) measure the diameter of the calves D) palpate for temperature in the feet
C
A nurse observes a decrease in hair extremities of an elderly client. what is an appropriate action by the nurse? A) check for ulcer in medial aspect of the ankles B) ask the patient about the presence of edema in the feet C) elevate the legs and observe for onset of pallow D) document this as a normal process of aging
C
A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the patients body should the nurse thoroughly examine to assess for the source of this finding A) head and neck for recent ear infection or sore throat B) abdomen, noting any organ enlargement or tenderness C) lower arm and hand for erythema and swelling D) cervical lymph nodes for tenderness and swelling
C
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect? A) varicose veins B) arterial occlusion C) thrombophlebitis D) venous insufficiency
C
The nurse is obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. The nurse is concerned about the possibility of arterial insufficiency and performs the Allen test. What does this mean? A) checked for patency of the femoral artery B) checked for patency of the radial artery C) checked for patency of the ulnar artery D) checked for patency of the brachial artery
C
A finding on palpation that suggests venous insufficiency is: A) ulcerations on toes of left foot B) cool lower legs and feet C) diminished sensations of dorsum of rt foot D) diminished dorsalis pedis pulse in an edematous foot
D
A nurse experiences difficulty in palpating the popliteal pulses in a client during assessment of the peripheral vascular system. What should the nurse do to assist in locating this pulse on a client? A) have the client cross the legs with the knee bent B) warm the legs to prevent vasoconstriction C) lower the leg so that it dangles off the bed D) place the client in the prone position
D
Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? A) 2+ B) 3+ C)1+ D) 4+
D
If palpable, superficial inguinal nodes are expected to be: A) fixed, tender, and at 2.5 cm in diameter B) fixed, nontender, and 1.5 cm in diameter C) discrete, tender and 2 cm in diameter D) nontender, mobile, and 1 cm in diameter
D
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect? A) venous insufficency B) arterial occlusion C) varicose veins D) thrombophlebitis
D
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect? A) venous insufficiency B) varicose veins C) arterial occlusion D) thrombophlebitis
D
The nurse palpates slightly enlarged epitrochlear nodes. The nurse should evaluate more closely which part of the body? A) neck B) axillae C) mouth D) fingers
D
Which of the following assessment findings is most congruent with chronic arterial insufficiency? A) brown pigmentation around a clients ankles and shins B) thickened and scarred skin on patients ankle C) ulcerations on medial surface of clients ankle D) cool ft temp and ulcerations on clients great toe
D
a nurse prepares to perform the manual compression test on a patient with which of the following? A) arterial occlusion B) lymphedema C) venous ulcer D) varicose veins
D
a nurse receives an order to perform a compression test to assess the competence of the valves in a patients varicose veins. which action by the nurse demonstrates the correct way to perform this test A) feel for a pulsation to the fingers in the lower hand B) ask the patient to sit on a chair for the exam C) place the second hand 3 to 5 inches above the first hand D) firmly compress the lower portion of the varicose vein
D
When assessing a client for possible varicose veins, which of the following would the nurse do?
Have the client stand for the exam
The radial pulse is palpated over the lateral flexor surface T/F
T
refers to the buildup of fats, cholesterol, and other substances in and on your artery walls
atherosclerosis
Name 4 risk factors for hypertension
smoking, genetics, diabetes, hyperlipidemia
