Chapter 22: Assessing Peripheral Vascular System

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 have a history of cardiovascular disease?" "Have you started any new medications?" "Do you notice your fingers changing colors?" "Are you exercising when this occurs?"

"Do you notice your fingers changing colors?" Explanation: Numbness, tingling, pain, and burning in the fingertips are findings of Raynaud's disease. Vasospasms or vasoconstriction occur in the fingers or toes and cause rapid changes in the color of the digits (pallor, cyanosis, redness). These vasospasms cause the numbness, tingling, and burning pain. New medications, cardiovascular disease, and exercise do not influence this process.

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 pain tells us what treatment will work best for you." -"The area of cramping indicates whether you may have numbness and tingling also." -"The area of pain can help us identify what risk factor is predominant." -"The area of cramping is close to the area of arterial occlusion."

"The area of cramping is close to the area of arterial occlusion." Explanation: The area of cramping in arterial disease, termed intermittent claudication, closely approximates the level of arterial occlusion. The other options are distracters to the question.

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person? -0.15 -0.25 -0.75 -1.00

1.00 Explanation: The ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABPI of approximately 1.00 or no arterial insufficiency. An ABPI of 0.25 or lower indicates severe stenosis leading to ischemia and tissue damage. An ABPI of 0.5 to 0.95 indicates mild to moderate arterial insufficiency

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 -A moderately painful wound on the lateral aspect of the client's ankle -A painless wound on the sole of the client's foot, which is surrounded by calloused skin -A wound on a client's highly edematous ankle that is surrounded by pigmented skin

A painless wound on the sole of the client's foot, which is surrounded by calloused skin Explanation: Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should be added to the plan of care? -Risk for peripheral neurovascular dysfunction -Activity intolerance related to pain and claudication with ambulation -Altered tissue perfusion, arterial related to reduced blood flow -Pain related to decreased blood flow and altered tissue perfusion

Altered tissue perfusion, arterial related to reduced blood flow Explanation: Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; dry skin; weak or absent pulses; pale skin; cool, reduced sensation; and prolonged capillary refill. The other options are distracters to the question.

What is a long-term complication of peripheral vascular disease? Metabolic changes Thickened skin Amputation Diabetes mellitus

Amputation Explanation: Diseases of the peripheral vascular system, peripheral arterial disease, venous stasis, and thromboembolic disorders can severely affect the lifestyle and quality of life of clients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation.

A client at risk for peripheral arterial disease should be screened by which of the following tests? -Ankle-brachial index -Doppler testing of femoral arteries -Bilateral vascular claudication assessment -Angiogram of femoral and popliteal arteries

Ankle-brachial index Explanation: The ABI is the primary screening tool used to detect asymptomatic or subclinical PAD.

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? -Venogram -CT scan of the lower legs -Ankle-brachial index (ABI) -PET scan

Ankle-brachial index (ABI) Explanation: The ABI is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Approximately 16% of clients with known peripheral vascular disease also have coronary artery disease.

The nurse is assessing blood flow in the lower extremities of a client. What should the nurse keep in mind when using a Doppler for this assessment? Select all that apply. -Apply warm gel to the areas on the extremity -Apply steady but gentle pressure over the area -Keep the extremity warm during the assessment -Listen for whooshing should that indicates a vein -Listen for a rushing sound that indicates an artery

Apply warm gel to the areas on the extremity Apply steady but gentle pressure over the area Keep the extremity warm during the assessment Explanation: When using a Doppler to assess for blood flow the nurse should apply warm gel to the areas on the extremity since cold gel will promote vasoconstriction and make it more difficult to detect a signal. The probe should not be pressed too tightly against the skin since this may obliterate the signal. A warm extremity will increase signal strength. A whooshing sound indicates an artery. A rushing sound indicates a vein.

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? -Deep vein thrombosis -Arterial occlusion -Pulmonary embolism -Venous thromboembolism

Arterial occlusion Explanation: Symptoms of a complete arterial occlusion includes pain, numbness, coolness, or color change of an extremity and is an emergency. A deep vein thrombosis is characterized by pain, edema and warmth of the extremity. Pulmonary embolism symptoms include acute dyspnea, chest pain, diaphoresis and anxiety. Venous thromboembolism occurs when a blood clot travels from the legs to the lungs.

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? -Attempt to palpate the posterior tibial pulse. -Assess adequacy of blood flow using a Doppler device. -Check the extremity for findings of decreased blood flow. -Obtain an order for ankle brachial index test to be performed.

Assess adequacy of blood flow using a Doppler device. Explanation: Arterial insufficiency causes a decrease in the amount of blood flow to an extremity. If the blood flow is diminished significantly, the adequacy of the pulse may also diminish. Therefore, if a pulse cannot be palpated, the nurse's best action is to obtain a Doppler device to assess for adequate blood flow. A Doppler device works by transmitting ultra-high-frequency sound waves in a way that they strike red blood cells in an artery or vein. This rebounding ultrasound waves produces a whooshing sound that is transmitted through the Doppler. Attempting to palpate the posterior tibial pulse does not provide information about the dorsalis pedis pulse. Checking the extremity for findings of decreased blood flow is not necessary because the nurse is already aware that the client has arterial insufficiency and needs to determine the extent, not the presence, of the disease. The ankle brachial index is a much more complex test that can be performed after the Doppler determines whether or not a pulse is present.

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? -Raise the foot of the bed for an hour and then lower it. -Massage lower extremities vigorously every 6 hours. -Assist in active range-of-motion exercise of the upper body. -Assist the client to walk as soon and as often as possible.

Assist the client to walk as soon and as often as possible. Explanation: Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

When assessing temperature of the skin, which portion of the hand should the examiner use? -Fingertips -Palms -Backs of fingers -Ulnar aspect of the hand

Backs of fingers Explanation: The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. The nurse may have difficulty detecting subtle differences without using the backs of the fingers.

A nurse is caring for a client diagnosed with chronic lymphedema. In preparing a teaching plan for this client, what would be essential for the nurse to address when considering psychosocial wellness? -Exercise plan -Body image -Treatment -Pathophysiology

Body image Explanation: Clients with chronic lymphedema may experience disfigurement that affects their body image and self-esteem. It is essential for nurses to address these areas that affect quality of life. Addressing exercise, treatment, and pathophysiology is not considered as essential for the nurse to address in teaching as are body image and self-esteem.

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward? Epitrochlear Radial Ulnar Brachial

Brachial Explanation: The brachial pulses are located at approximately the inner third of the antecubital fossa when the palm is held up. It is not usually necessary to palpate the ulnar pulse, which is difficult to locate. The radial pulse site is used when assessing the pulse for vital signs. Epitrochlear is not a term used to identify a pulse.

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? Thigh Knee Calf Ankle

Calf Explanation: Pain in the calf is the most common site for claudication; however, there could be pain in the buttock, hip, thigh, or foot depending on the level of the obstruction. Absence of this pain does not rule out significant vascular disease, actually, the minority of these clients are symptomatic.

The client is experiencing septic shock. What assessment finding would the nurse expect to find? -Blood pressure 128/76 -Capillary refill greater than 2 seconds -Warm extremities -Normal temperature

Capillary refill greater than 2 seconds Explanation: The client experiencing septic shock would have a capillary refill greater than 2 seconds. The temperature may or many not be normal, blood pressure would be low and extremities would be cool.

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 Regular exercise Stress-reduction techniques Low alcohol intake Previous use of hormones High-fat diet

Cigarette smoking Previous use of hormones High-fat diet Explanation: The risk factors for the development of peripheral vascular disease include smoking, lack of exercise, high stress, moderate to high alcohol intake, previous use of hormonal birth control (females), and a 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 -Cool legs bilaterally -Cool leg on one side -Capillary refill less than 2 seconds

Cold fingers and hands Explanation: Raynaud's is exhibited by cold fingers and hands. Cool extremities could be due to a cool room or arterial insufficiency. A capillary refill of less than 2 seconds is normal.

Which of the following assessment findings is most congruent with chronic arterial insufficiency? -Brown pigmentation around a client's ankles and shins -Ulceration on the medial surface of the client's ankle -Thickened and scarred skin on the client's ankle -Cool foot temperature and ulceration on the client's great toe

Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

The nurse is going to assess a client's ankle-brachial index. Which equipment will the nurse use for this assessment? Select all that apply. -Tape measure -Stethoscope -Doppler device -Blood pressure cuff -Reflex hammer

Doppler device Blood pressure cuff Explanation: To assess the ankle-brachial index, the nurse will apply a blood pressure cuff above the client's malleolus. The Doppler device is used to hear the blood flow as the blood pressure cuff is released. A tape measure, stethoscope, or reflex hammer is not used to assess the ankle-brachial index.

A nurse observes a decrease in hair on the lower extremities of an elderly client. What is an appropriate action by the nurse in regards to this finding? Document this as a normal process of aging. Check for ulcers on the medial aspect of the ankles. Ask the client about the presence of edema in the feet. Elevate the legs and observe for the onset of pallor.

Elevate the legs and observe for the onset of pallor. Explanation: Loss of hair can be a normal finding in the elderly client, but the nurse should perform further assessment before making this judgment. Loss of hair is seen with arterial insufficiency. Ulcers on the medial aspect of the ankle are a sign of venous stasis as is the presence of edema. Pallor, or loss of color, is seen in arterial insufficiency, especially when the legs are elevated.

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? -Observe for gangrene areas. -Elevate the legs on pillows. -Assess for diminished pulses. -Lower the legs below heart level.

Elevate the legs on pillows. Explanation: Common complaints of venous ulcer pain include: aching pain and feeling of heaviness which is relieved with elevation of the legs. Relief for arterial ulcer pain is achieved by dependently positioning the legs below the heart. Gangrene and decreased pulses more commonly occur with arterial ulcers; assessing for these symptoms doesn't address the client's pain.

A nurse palpates a weak left radial artery on a client. What should the nurse do next? Palpate both radial arteries for symmetry. Assess the left hand for pallor and coolness. Palpate the left ulnar artery. Document the finding in the client's record.

Explanation: Extremities should always be assessed simultaneously for symmetry. If the radial arteries are both weak, this may indicate a problem with peripheral circulation. The nurse should then assess the ulnar artery pulses to determine the presence of arterial insufficiency. The hands should be assessed for pallor and coolness, which would also be present with arterial insufficiency. All findings should be documented in the client's record.

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? -Exercise tolerance -Prevention of varicose veins -Extent of tobacco use and exposure -Significance of cardiac dysrhythmias

Extent of tobacco use and exposure Explanation: Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias.

Which of the following arteries can be palpated below the inguinal ligament between the anterior superior iliac spine and the symphysis pubis? Femoral artery Popliteal artery Dorsalis pedis artery Ulnar artery

Femoral artery Explanation: The femoral artery may be felt in the given location, while the popliteal and dorsalis pedis arteries are both distal to this point. The ulnar artery is located in the arm.

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? -Ask the client to sit on a chair for the examination -Firmly compress the lower portion of the varicose vein -Place the second hand 3 to 4 inches above the first hand -Feel for a pulsation to the fingers in the lower hand

Firmly compress the lower portion of the varicose vein Explanation: The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

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? Ask the client to sit on a chair for the examination Firmly compress the lower portion of the varicose vein Place the second hand 3 to 4 inches above the first hand Feel for a pulsation to the fingers in the lower hand

Firmly compress the lower portion of the varicose vein Explanation: The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

x 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? -Ask the client to sit on a chair for the examination -Firmly compress the lower portion of the varicose vein -Place the second hand 3 to 4 inches above the first hand -Feel for a pulsation to the fingers in the lower hand

Firmly compress the lower portion of the varicose vein Explanation: The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

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 Raynaud's disorder Presence of peripheral artery disease History of breast surgery Presence of deep vein thrombosis

History of breast surgery Explanation: Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Raynaud's disorder is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes and is typically bilateral. Peripheral artery disease involves reduced blood flow to the limbs and is characterized primarily by intermittent claudication, not by edema. Deep vein thrombosis is caused by obstruction of the veins and is not associated with lymphedema.

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: -Arterial insufficiency -Venous insufficiency -Diminished sensation in pressure points -Hypertension

Hypertension Explanation: Hypertension is not directly associated with the formation of ulcers. It is an indirect risk factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to arterial insufficiency or neuropathy.

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 -Obesity -Smoking -Hypertension

Immobility Explanation: Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis. Obesity is a risk factor for the development of arterial and venous disease. Smoking is a risk factor for arterial and venous disease and for the development of an abdominal aortic aneurysm. Hypertension is a risk factor for arterial disease and abdominal aortic aneurysm.

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? -Fear of Loss of Extremity -Impaired Skin Integrity -Risk for Skin Breakdown -Imbalanced Nutrition

Impaired Skin Integrity Explanation: This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented.

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 -Chest pressure with exertion -Shortness of breath -Knee pain

Intermittent claudication Explanation: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral arterial disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.

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 -Pulmonary embolism -Deep vein thrombosis -Varicose veins

Intermittent claudication Explanation: Pain brought on by exertion and relieved by rest is called intermittent claudication. Varicose veins are due to incompetent valves. Signs of a pulmonary embolus include acute dyspnea, chest pain, tachycardia, diaphoresis, a anxiety. Deep vein thrombosis symptoms include pain, edema, and warmth of an extremity.

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 -Tourniquet should be put on before leg elevation -Have the client stand upright after tourniquet removal -Ensure that the client's legs are over the side of the bed

Legs should be elevated for 15 seconds Explanation: When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.

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? -Have the client sit down -Use a Doppler ultrasound device on the client's leg -Lightly palpate the client's leg veins for tenderness -Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe

Lightly palpate the client's leg veins for tenderness Explanation: To fully assess for a suspected phlebitis, lightly palpate for tenderness. The client should still be standing from the inspection of the legs. A Doppler ultrasound device is used to assess for pulses when they are difficult to palpate. Dorsiflexing the client's foot and applying light pressure along the extensor tendon of the big toe are done when palpating for the dorsalis pedis pulses.

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? Cervical lymph nodes for tenderness and swelling Abdomen, noting any organ enlargement or tenderness Head and neck for recent ear infection or sore throat Lower arm and hand for erythema and swelling

Lower arm and hand for erythema and swelling Explanation: The epitrochlear nodes are located in the upper inside of the arm. Enlargement of these nodes may indicate infection in the hand or forearm or they may occur with generalized lymphadenopathy. Cervical lymph nodes are part of the system that drains the head and neck, and enlargement would be due to a recent ear infection, sore throat, or other upper respiratory tract infection. Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area.

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication? -Lymphedema -Peripheral arterial disease -Venous stasis -Varicose veins

Lymphedema Explanation: Lymphedema can be a result of scarring injury, removal of lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused by decreased arterial blood supply. Venous stasis is due to blood not moving which puts the client at risk for varicose veins.

If palpable, superficial inguinal nodes are expected to be: -Fixed, tender, and at 2.5 cm in diameter -Discrete, tender, and 2 cm in diameter -Nontender, mobile, and 1 cm in diameter -Fixed, nontender, and 1.5 cm in diameter

Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

If palpable, superficial inguinal nodes are expected to be: Fixed, tender, and at 2.5 cm in diameter Discrete, tender, and 2 cm in diameter Nontender, mobile, and 1 cm in diameter Fixed, nontender, and 1.5 cm in diameter

Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 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? Encourage early ambulation. Assist the client to turn, cough, and deep breathe. Discontinue the indwelling urinary catheter. Notify the healthcare provider

Notify the healthcare provider. Explanation: The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot. Prevention of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a urinary tract infection include pain, increased white blood cells, and fever.

Symptoms of complete arterial occlusion include which of the following? Select all that apply. -Numbness -Color change -Pain -Erythema -Heat

Numbness Color change Pain Explanation: If the client is experiencing symptoms of complete arterial occlusion such as pain, numbness, coolness, or color change of an extremity, the nurse should stop the assessment and get help. A limb with a complete arterial occlusion would not be erythematous or warm to touch.

A nurse is having difficulty palpating a client's dorsalis pedal pulses. What is the best action of the nurse? Place the client's leg in a dependent position to improve blood flow. Warm the client's feet in warm water to improve circulation. Assess the client's ankle-brachial index (ABI). Obtain a Doppler ultrasound device.

Obtain a Doppler ultrasound device. Explanation: If the nurse is having difficulty palpating pulses, a Doppler ultrasound device should be used. Placing the client's feet in warm water or in a dependent position may help improve blood flow, but these are not the best actions for this situation. Assessing the client's ankle-brachial index will not help assess the client's pulse.

A nurse palpates a weak left radial artery on a client. What should the nurse do next? -Palpate both radial arteries for symmetry. -Assess the left hand for pallor and coolness. -Palpate the left ulnar artery. -Document the finding in the client's record.

Palpate both radial arteries for symmetry. Explanation: Extremities should always be assessed simultaneously for symmetry. If the radial arteries are both weak, this may indicate a problem with peripheral circulation. The nurse should then assess the ulnar artery pulses to determine the presence of arterial insufficiency. The hands should be assessed for pallor and coolness, which would also be present with arterial insufficiency. All findings should be documented in the client's record.

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? -Advanced chronic arterial occlusive disease -Neuropathy secondary to diabetes -Venous disease -Peripheral arterial disease

Peripheral arterial disease Explanation: Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.

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? -Obstruction in the femoral artery -Peripheral vascular problems -Diabetes mellitus -Calcium deficiency

Peripheral vascular problems Explanation: The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.

While performing an assessment the nurse presses the client's arm with the tip of her thumb, holds for a few seconds and releases. The nurse observes the client as shown. What is the nurse assessing? -Pitting edema -Capillary refill -Peripheral pulses -Skin temperature

Pitting edema Explanation: Pitting edema is associated with systemic problems, such as congestive heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting (orthostatic edema)

What pulse is located in the groove between the medial malleolus and the Achilles tendon? Posterior tibial Dorsalis pedis Popliteal Femoral

Posterior tibial Explanation: The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

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 -Regular exercise -Stress-reduction techniques -Low alcohol intake -Previous use of hormones -High-fat diet

Previous use of hormones High-fat diet Cigarette smoking Explanation: The risk factors for the development of peripheral vascular disease include smoking, lack of exercise, high stress, moderate to high alcohol intake, previous use of hormonal birth control (females), and a high-fat diet.

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? -If you develop swelling in your ankles or feet, then you should seek emergency care. -Quitting smoking and keeping good control of your blood sugar levels are important. -It's critical that you come to get screening tests twice annually. -I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD.

Quitting smoking and keeping good control of your blood sugar levels are important. Explanation: Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests.

A student in the vascular surgery clinic is asked to perform a physical examination on a client with known peripheral vascular disease in the legs. Which of the following aspects are most important to note? -Size, symmetry, and skin color -Muscle bulk and tone -Nodules in joints -Lower extremity strength

Size, symmetry, and skin color Explanation: Size, symmetry, and skin color are important aspects to note in physical examination. Swelling in the legs, cyanosis, and lack of appropriate hair growth are all signs of peripheral vascular disease.

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply. -Smoking -Overweight -Lack of exercise -Family history -Ethnicity

Smoking Overweight Lack of exercise Explanation: Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors.

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? Normal pulsation Normal temperature Marked edema Thin, shiny, atrophic skin

Thin, shiny, atrophic skin Explanation: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.

The radial pulse is palpated over the lateral flexor surface. True False

True

Which of the following veins drain into the superior vena cava? (Mark all that apply.) Lower extremities Upper torso Head Upper extremities Lower torso

Upper torso Head Upper extremities Explanation: The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium. The lower extremities and lower torso drain into the inferior vena cava.

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? -Decreased mobility -Sepsis -Venous thromboembolism -Fluid imbalance

Venous thromboembolism Explanation: Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism.

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 Arterial occlusion Neuropathy Venous obstruction

Venous thromboembolism Explanation: Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism. Arterial occlusion is characterized by pain with exercise. Neuropathy is characterized by no pain. Symptoms of a venous occlusion would include edema.

A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client? -Cold, pale skin on the extremities -Shiny skin, with loss of hair over the lower legs -Warm skin and brown pigmentation around the ankles -Clammy skin on the extremities

Warm skin and brown pigmentation around the ankles Explanation: Warm skin and brown pigmentation around the ankles are associated with venous insufficiency. Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency.

The nurse reads the previous shift's assessment documentation and notes local swelling, redness, and warmth. The oncoming nurse palpates a subcutaneous cord and suspects a superficial thrombophlebitis deep vein thrombosis venous insufficiency femoral aneurysm

a superficial thrombophlebitis Explanation: Superficial vein thrombophlebitis is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted.

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 -venous stasis. -varicose veins. -thrombophlebitis. -arterial insufficiency.

arterial insufficiency. Explanation: Manifestations of arterial insufficiency include intermittent claudication to sharp, unrelenting, and constant. Diminished or absent pulses. Skin in cool to cold in temperature and there is a loss of hair over the toes and dorsum of the foot.

The largest arteries of the upper extremities are the -brachial arteries -subclavian arteries -abdominal arteries -radial arteries

brachial arteries Explanation: The largest arteries of the upper extremities are the brachial arteries.

The nurse documents a 2+ radial pulse. What assessment data indicated this result? -brisk, expected (normal) pulse -bounding pulse -diminished pulse -absent (unable to palpate) pulse

brisk, expected (normal) pulse Explanation: A +2 pulse is a normal pulse.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder? -deep vein thrombosis -compartment syndrome -acute lymphangitis -acute cellulitis

deep vein thrombosis Explanation: Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphylococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder? deep vein thrombosis compartment syndrome acute lymphangitis acute cellulitis

deep vein thrombosis Explanation: Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphylococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues.

The nurse assesses edema in a newly admitted client. Further evaluation is based on the fact that the nurse knows edema is caused by (Select all that apply.) -increased capillary blood pressure -increased capillary membrane permeability -low plasma protein levels -blockage of lymphatic drainage -colloid osmotic pressure

increased capillary blood pressure increased capillary membrane permeability low plasma protein levels blockage of lymphatic drainage

The nurse assesses edema in a newly admitted client. Further evaluation is based on the fact that the nurse knows edema is caused by (Select all that apply.) increased capillary blood pressure increased capillary membrane permeability low plasma protein levels blockage of lymphatic drainage colloid osmotic pressure

increased capillary blood pressure increased capillary membrane permeability low plasma protein levels blockage of lymphatic drainage

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for -lymphedema. -Raynaud disease. -poor peripheral pulses. -bruits over the radial artery.

lymphedema. Explanation: Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.

The radial pulse is palpated over the lateral flexor surface. -True -False

na

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? -lumbar node -right cervical node -superficial inguinal node -superficial popliteal node

right cervical node Explanation: The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct.

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client? atherosclerosis arterial insufficiency venous insufficiency deep vein thrombosis

venous insufficiency Explanation: Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.

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. arterial occlusive disease. venous ulcers. ankle edema.

venous insufficiency. Explanation: Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus.