Chapter 21, Peripheral Vascular System and Lymphatic System

Which conditions would the nurse check for in the patient's medical record who has a diagnosis of peripheral artery disease (PAD) before determining the ABI? Select all that apply.

Renal failure Diabetes mellitus

Which condition would the nurse infer from the patient's statement, "I wake up in the middle of the night because of sudden pain in my legs"?

Restless legs syndrome

Which actions may aggravate the symptoms of venous insufficiency? Select all that apply.

Sitting Prolonged standing

Which nursing intervention will help the patient who has brawny edema and unilateral swelling and who complains of "heavy arms"? Select all that apply.

Suggesting that the patient use nonelastic garments Suggesting that the patient use compression garments Advising the patient to perform decongestive physiotherapy

Which signs and symptoms in addition to cyanosis would support the diagnosis of Raynaud phenomenon? Select all that apply.

Swelling in the arms Burning pain in the arms

The patient with severe leg pain, edema, and weeping ulcers on the leg tells the nurse, "My leg pain gets worse by the end of the day, but it feels a bit better when I walk or lie on the bed." Which would the nurse interpret from these signs and symptoms?

The patient has chronic venous pain.

Which findings support the nurse's documentation of +4 pitting edema? Select all that apply.

The patient has very deep pitting. The patient has grossly swollen legs. The patient has indentation of long duration.

While assessing a patient with an infection of the forearm, the nurse uses one hand to shake the patient's hand and keeps the other hand near the patient's elbow. Which is the reason for the nurse's action?

To check for enlarged epitrochlear nodes

Which concomitant condition would make the assessment of leg discoloration because of arterial insufficiency unreliable?

Venous disease

Which nursing actions are appropriate during a peripheral vascular examination? Select all that apply.

Checking the epitrochlear nodes of the patient Palpating the femoral pulse of the patient Palpating the inguinal nodes of the patient

Which would the nurse expect to find in the laboratory report when palpating the radial artery as a 3+ amplitude? Select all that apply.

Decreased red blood cell count Increased serum thyroxine levels

Which condition in the patient correlates with venous insufficiency and edema in the lower extremities, with thick and brownish discoloration of the skin?

Degradation of red blood cells

Which disorders can cause calcification of the arteries?

Diabetes mellitus

Which technique is useful when assessing a patient with chronic venous insufficiency who has dilated, tortuous veins and reports severe leg cramps??

Doppler ultrasound

Which increased serum level leads the nurse to conclude the patient is at risk of atherosclerosis? Select all that apply.

Glucose Cholesterol Triglycerides

A patient who is in the third trimester of pregnancy has increased venous pressure and reduced blood flow because of obstruction of the iliac veins and inferior vena cava. Which complications may the patient develop related to these findings? Select all that apply.

Hemorrhoids Varicosities in the vulva Varicosities in the leg

During a vascular assessment, the nurse documents a capillary refill time of 5 seconds and knows that the patient is at risk for which condition?

Hypovolemia

Which would be the likely reason an adolescent patient with an upper respiratory tract infection complains of abdominal pain?

Inflammation of the mesenteric lymph nodes

The nursing instructor is talking with a nursing student about the superficial nodes of the lymphatic system that are accessible to inspection and palpation. Which statement by the nursing student indicates effective learning?

"Cervical nodes drain the head and neck."

Which statements, if made by the nursing student, indicate effective learning about the functions of the lymphatic system? Select all that apply.

"The lymphatic system is a major part of the immune system in the body." "The lymphatic system helps in the absorption of lipids from the small intestine." "The lymphatic system conserves the plasma proteins that leak out of the capillaries."

Which statements by the student nurse correctly describes the function of the spleen? Select all that apply.

"The spleen produces antibodies." "The spleen destroys old red blood cells." "The spleen filters microorganisms from the blood."

Which would the nurse do to assess the probability of DVT in the patient?

Measure the calf circumference of both legs at the same place.

Which would the nurse deduce from the patient's ankle-brachial index (ABI) of 0.85?

Mild peripheral artery disease Rationale The ABI is the index that helps measure the severity of peripheral artery disease (PAD). It can be determined by dividing the left average ankle pressure by the left or right highest average arm pressure. An ABI in the range of 0.90 to 0.71 indicates a mild risk of PAD. In this case, because the patient's ABI is 0.85, the nurse would conclude that the patient has mild PAD. An ABI of 0.40 to 0.30 indicates severe PAD. If a patient's ABI is more than 0.90, then it indicates that the patient has a borderline risk of PAD. If a patient's ABI is 0.70 to 0.41, then it indicates that the patient has moderate PAD.

Which conditions are associated with venous pooling? Select all that apply.

Obesity Multiple pregnancie

While assessing the radial pulse of the patient, the nurse finds that the strength of the pulse increases rapidly and collapses subsequently. Which conditions may be responsible for this finding in the patient? Select all that apply.

Patent ductus arteriosus Aortic valve regurgitation

Which technique would the nurse use when assessing a patient with congenital cyanotic heart disease who has a flattened nail bed angle and diffuse enlargement of the terminal phalanges?

Profile sign

For which complications would the nurse monitor in a patient with deep vein thrombosis?

Pulmonary embolism

Which condition is the patient with bilateral pitting edema and abnormal distention of the jugular veins likely to have?

Pulmonary hypertension

While assessing the probability of a deep vein thrombosis on a patient, the nurse documents the clinical characteristics as follows: 1. Swelling of the entire leg 2. Collateral superficial nonvaricose veins 3. Localized tenderness along the distribution of the deep venous system What is the total score of DVT probability in this patient? Record your answer using a

1

Which conditions are likely to be associated with a patient's blood pressure at 85/60 mm Hg for inspiration and 110/60 mm Hg for expiration? Select all that apply.

Acute asthma Cardiac tamponade

Which can the nurse infer when assessing a patient with an easily palpable pulse that pounds under the fingertips? Select all that apply.

Anemia Hyperkinetic state Hyperthyroidism

Which class of medications would be most beneficial for a bedridden patient who reports sudden sharp pain the legs, which upon assessment are found to be warm, red, and edematous?

Anticoagulants

The nurse is finding it difficult to locate an older adult patient's pulse. After palpating the patient's arm for some time, the nurse locates the pulse but notices it is obliterated on applying pressure. Which would correlate with these findings? Select all that apply.

Aortic valve stenosis Decreased cardiac output Peripheral arterial disease

A patient with atherosclerosis complains of foot pain while walking and at rest, and the nurse finds that the patient has pale skin and rigid nails. Which complication would the nurse expect in the patient?

Arterial ischemic ulcer

If the patient is complaining of severe leg pain and the ankle-brachial index (ABI) is 0.65, which conditions would the nurse check for in the medical records? Select all that apply.

Arthriti Peripheral neuropathy

Which supports the nurse's documentation of moderate lymphedema after taking asymmetric measurements of the calves?

Asymmetry of calves measuring 4.0 cm