Chapter 18 Prep U

A nurse is determining a client's ankle-brachial index. Which result would indicate to the nurse that the client's circulation is normal and free of arterial occlusion?

1.1

When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency?

14 year history of smoking a pack a day

A nurse is auscultating a client's chest for breath sounds. The nurse recognizes that which of the following is the strongest stimulus to breathe?

Hypercapina

Which assessment finding would support the diagnosis of pericardial tamponade?

Systolic blood pressure decreases from 140 mm Hg to 127 mm Hg during inspiration.

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

a painless wound on the sole of the clinets foot, which is surrounded by calloused skin

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?

Emphysema

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

COPD

A nursing instructor is discussing variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax?

Caucasians

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:

arterial insufficiency ulcers

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

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which statement would the nurse include in the response?

arteries have thicker walls than veins

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

ask the client to breathe deeply through her mouth

The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate?

behind the ankle

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

chronic bronchitis

When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency?

cigarette smoking

A patient is diagnosed with pleuritis. What will the nurse most likely assess in this patient?

decreased breath sounds

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?

extent of tobacco and exposure

The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse?

femoral

When assessing a client for possible varicose veins, which of the following would the nurse d

have the client stand for the exam

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process?

heart failure

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

immobitity

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data?

impaired skin integrity

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

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

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

manubrium

when auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following

one deep inspiration and expiration through the open mouth

A 42-year-old woman reveals an intake of medications. Which medication if reported by the client would alert the nurse to the need to assess the client for thrombophlebitis?

oral contraceptive

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

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?

right cervical node

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?

slight kyphosis

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound?

sound heard throughout inspiration and 2/3 of expiration

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

suprasternal notch

The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?

the pattern is expected with this condition

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

Patients with PAD need to understand why it is important to monitor

triglyceride levels

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

unequal expansion of the chest