Chapter 22: Assessing Peripheral Vascular System

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a) Legs should be elevated for 15 seconds b) Ensure that the client's legs are over the side of the bed c) Have the client stand upright after tourniquet removal d) Tourniquet should be put on before leg elevation

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

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

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

A +2 pulse is a normal pulse. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 22: Assessing Peripheral Vascular System, p. 468

Which of the following wounds is most likely attributable to neuropathy? a) A wound on a client's highly edematous ankle that is surrounded by pigmented skin b) A moderately painful wound on the lateral aspect of the client's ankle c) A painless wound on the sole of the client's foot, which is surrounded by calloused skin d) A painful wound in the client's shin, which is surrounded by apparently healthy 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.

A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding? a) Cervical lymph nodes for tenderness and swelling b) Lower arm and hand for erythema and swelling c) Abdomen, noting any organ enlargement or tenderness d) Head and neck for recent ear infection or sore throat

Abdomen, noting any organ enlargement or tenderness Explanation: Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area. 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

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 this client receive? a) Altered tissue perfusion, arterial related to reduced blood flow b) Risk for peripheral neurovascular dysfunction c) Pain related to decreased blood flow and altered tissue perfusion d) Activity intolerance related to pain and claudication with ambulation

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.

When assessing temperature of the skin, which portion of the hand should the examiner use? a) Backs of fingers b) Palms c) Fingertips d) 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

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

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. There is no epitrochlear pulse

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

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

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching? a) Check feet daily for cuts or pressure areas. b) Report any changes in skin or hair appearance to health care provider. c) Wear compression stockings at all times. d) Disfigurement is common in clients with peripheral arterial disease.

Check feet daily for cuts or pressure areas. Explanation: Because of decreased blood flow, the client needs to check feet daily for cuts or pressure areas so that treatment to prevent arterial ulcers can begin immediately. Compression stockings should not be worn by clients with peripheral arterial disease. Disfigurement is not common in clients with peripheral arterial disease. There will be decreased hair and the skin will be shiny in clients with peripheral arterial disease.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action? a) Flush all ports with heparin solution. b) Discontinue the central line. c) Check the insertion site for redness. d) Culture the tip of the central line.

Check the insertion site for redness Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip. Flushing the ports with saline can assist the nurse in checking patency of the lines

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? a) Prevention of varicose veins b) Exercise tolerance c) Extent of tobacco use and exposure d) 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? a) Ulnar artery b) Dorsalis pedis artery c) Femoral artery d) Popliteal 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? a) Place the second hand 3 to 4 inches above the first hand b) Feel for a pulsation to the fingers in the lower hand c) Firmly compress the lower portion of the varicose vein d) Ask the client to sit on a chair for the examination

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.

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment? a) Plan for modifying risk factors b) History related to grandparents' health c) Education on nonmodifiable risk factors d) Identification of cardiovascular risk factors

Identification of cardiovascular risk factors Correct Explanation: The subjective portion of the health assessment includes the identification of cardiovascular risk factors and history related to those symptoms that are frequently associated with arterial, venous, and lymphatic disorders. The subjective portion of the health assessment would not include a plan for modifying risk factors, education on nonmodifiable risk factors, or a history of the grandparents' health.

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? a) Hypertension b) Obesity c) Smoking d) Immobility

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 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? a) Peripheral arterial disease b) Neuropathy secondary to diabetes c) Advanced chronic arterial occlusive disease d) Venous 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 nurse performs an ankle-brachial pressure index (ABPI) and obtains these results: R arm Blood Pressure 140/90 mmHg, L arm Blood Pressure 150/90 mmHg; R ankle 80 mmHG, L ankle 85 mmHg. Determine the right & left ABPI. a) Right 0.57: Left 0.60 b) Right 0.88; Left 0.94 c) Right 1.75; Left 1.76 d) Right 0.53; Left 0.56

Right 0.53; Left 0.56 Explanation: The ABPI determines the degree of arterial insufficiency in a person with peripheral arterial disease. It detects decreased systolic pressure distal to the area of stenosis or arterial narrowing & allows the nurse to quantify this measurement. It can be calculated by dividing the higher ankle pressure for each foot by the higher brachial pressure. Right ABPI: 80/150 = 0.53; Left ABPI: 85/150 = 0.56

The nurse is assessing the client's skin an ulcer is identified. What would indicate to the nurse it is a venous ulcer? a) The ulcer is necrotic. b) The client voices pain related to the ulcer. c) The extremity is without a pulse. d) The ulcer is superficial and pale.

The ulcer is superficial and pale. Explanation: A venous ulcer is superficial and pale. Arterial ulcers have a deep necrotic base, are painful and are related to decreased blood flow or pulselessness.

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) Marked edema b) Normal pulsation c) Normal temperature d) 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.

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

Upper extremities • Head • Upper torso 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.

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what? a) Arterial insufficiency b) Hypertrophic changes c) Intermittent claudication d) Venous insufficiency

Venous insufficiency Explanation: Venous insufficiency is characterized by aching, cramping, pigment changes. If the client has an ulcer, it will be painful. Arterial insufficiency is characterized by decreased pulses, dry, shiny, cold skin. Intermittent claudication is pain brought on by exertion and relieved by rest. Hypertrophic changes include a loss of hair and pallor

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

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

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's a) brachial pulse. b) tibial pulse. c) popliteal pulse. d) femoral pulse.

brachial pulse. Explanation: You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.

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

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 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? a) "I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD." b) "It's critical that you come to get screening tests twice annually." c) "Quitting smoking and keeping good control of your blood sugar levels are important." d) "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." 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 client presents with pitting edema to the left foot, which a 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) 3+ c) 4+ d) 2+

3+ Explanation: Pitting edema that produces a noticeably deep pit when the area is depressed and the extremity looks larger than the other is documented as 3+. A 1+ pitting edema is edema that produces slight pitting when the area is depressed. A 2+ is deeper than 1+. A 4+ pitting edema is a very deep pit in the area when depressed, and there is gross edema in the extremity

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) Avoid prolonged sitting and standing. b) Participate in daily exercise. c) Limit alcohol intake. d) Achieve a normal body weight. e) Drink an adequate amount of fluids.

Achieve a normal body weight. • Drink an adequate amount of fluids. • Avoid prolonged sitting and standing. • Participate in daily exercise. Explanation: For the patient at risk for developing venous disease, the nurse should instruct the patient to achieve a normal body weight, avoid dehydration, avoid prolonged sitting and standing, and participate in an exercise program. Limiting alcohol intake would be appropriate for the patient at risk for developing arterial disease.

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

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 patients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation.

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? a) Venogram b) Ankle-brachial index (ABI) c) CT scan of the lower legs d) 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 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? a) Arterial occlusion b) Pulmonary embolism c) Venous thromboembolism d) Deep vein thrombosis

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

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? a) Assist in active range-of-motion exercise of the upper body. b) Raise the foot of the bed for an hour and then lower it. c) Massage lower extremities vigorously every 6 hours. d) 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.

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find? a) Capillary refill less than 2 seconds b) Cold fingers and hands c) Cool leg on one side d) Cool legs bilaterally

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? a) Cool foot temperature and ulceration on the client's great toe b) Brown pigmentation around a client's ankles and shins c) Ulceration on the medial surface of the client's ankle d) Thickened and scarred skin on the client's ankle

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

A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency? a) Moderate to severe leg edema b) Painful ulcer with irregular border c) Deep ulcers that often involve joint space d) Ulcer commonly located in anterior tibial area

Deep ulcers that often involve joint space Explanation: Clients with ulcers due to arterial insufficiency usually have deep ulcers that often involve joint space. Ulcers due to venous insufficiency may be located in the anterior tibial area, have irregular borders, and are associated with moderate to severe edema. Ulcers due to arterial insufficiency are located on tips of toes, toe webs, heels, or other pressure areas if confined to bed. These ulcers are painful and circular in shape.

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease? a) Venous disease b) Peripheral arterial disease c) Lymphedema d) Diabetes

Diabetes Explanation: Clients with decreased or no pain sensation should be asked about a history of diabetes as it may be related to diabetic neuropathy. Peripheral arterial diease is characterized by pain. Venous disease is accompanied by heaviness and an aching sensation. Lymphedema is characterized by nonpitting edema

In assessing a client, a nurse palpates her epitrochlear lymph nodes and notes that the client may have an infection in the hand or forearm. The nurse understands that which of the following are functions of the lymphatic system? Select all that apply. a) Absorbs fats from the small intestine into the bloodstream b) Traps and destroys microorganisms and foreign materials filtered from lymph c) Returns blood to the heart d) Drains excess fluid and plasma proteins from tissues and returns them to the venous system e) Delivers oxygen, water, and nutrients to the tissues

Drains excess fluid and plasma proteins from tissues and returns them to the venous system • Traps and destroys microorganisms and foreign materials filtered from lymph • Absorbs fats from the small intestine into the bloodstream Explanation: The primary function of the lymphatic system is to drain excess fluid and plasma proteins from bodily tissues and return them to the venous system. These capillaries join to form larger vessels that pass through filters known as lymph nodes. The filtering, trapping, and destruction of microorganisms, foreign materials, dead blood cells, and abnormal cells by the lymph nodes allows the lymphatic system to perform a second function as a major part of the immune system defending the body against microorganisms. A third function of the lymphatic system is to absorb fats (lipids) from the small intestine into the bloodstream. The capillaries, not the lymphatic system, deliver oxygen, water, and nutrients to the tissues. Veins, not the lymphatic system, return blood to the heart.

When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization? a) Venous thromboembolism b) Fluid imbalance c) Sepsis d) Decreased mobility

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

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? a) Document this as a normal process of aging. b) Ask the client about the presence of edema in the feet. c) Elevate the legs and observe for the onset of pallor. d) Check for ulcers on the medial aspect of the ankles.

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? a) Observe for gangrene areas. b) Assess for diminished pulses. c) Elevate the legs on pillows. d) Lower the legs below heart level.

Elevate the legs on pillows. 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 performs the Allen 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) Have the client rest the hand palm side up and make a fist b) Use the thumbs to occlude the radial and ulnar arteries c) Ensure that the client's hand is not opened in exaggerated extension d) Keep both arteries occluded and have the client release the fist

Ensure that the client's hand is not opened in exaggerated extension Explanation: Opening the hand into exaggerated extension may cause persistent pallor, giving a false-positive test; the nurse should ensure that the client's hand is not opened in exaggerated extension. To perform the test, the nurse is required to have the client rest the hand palm side up and make a fist, use the thumbs to occlude the radial and ulnar arteries, and keep both arteries occluded and have the client release the fist.

Walking contracts the calf muscles and forces blood away from the heart. a) True b) False

False p. 447.

A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding? a) Presence of deep vein thrombosis b) Presence of peripheral artery disease c) History of breast surgery d) History of Raynaud's disorder

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: a) Hypertension b) Diminished sensation in pressure points c) Arterial insufficiency d) Venous insufficiency

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.

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) Chest pressure with exertion b) Intermittent claudication c) Shortness of breath d) 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 vascular 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.

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a) Legs should be elevated for 15 seconds b) Have the client stand upright after tourniquet removal c) Tourniquet should be put on before leg elevation d) 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 performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a) Tourniquet should be put on before leg elevation b) Have the client stand upright after tourniquet removal c) Ensure that the client's legs are over the side of the bed d) Legs should be elevated for 15 seconds

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

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? a) Head and neck for recent ear infection or sore throat b) Lower arm and hand for erythema and swelling c) Abdomen, noting any organ enlargement or tenderness d) Cervical lymph nodes for tenderness 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? a) Peripheral arterial disease b) Varicose veins c) Lymphedema d) Venous stasis

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: a) Nontender, mobile, and 1 cm in diameter b) Fixed, nontender, and 1.5 cm in diameter c) Fixed, tender, and at 2.5 cm in diameter d) Discrete, tender, and 2 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. Reference: p. 461.

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate? a) No lymphedema b) Atherosclerosis c) Possible lymphoma d) Normal finding

Normal finding Explanation: Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action? a) Discontinue the indwelling urinary catheter. b) Encourage early ambulation. c) Assist the client to turn, cough, and deep breathe. d) 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.

A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency? a) Ulcer located on medial malleolus b) Reports of aching, cramping pain c) Irregular-shaped ulcer on the inner aspect of the ankle d) Pallor of foot occurs with elevation

Pallor of foot occurs with elevation Explanation: Ulcers due to arterial insufficiency would have elevation pallor of the foot due to poor blood supply. Aching and cramping pain is present in ulcers caused by venous insufficiency. Irregular-shaped ulcers and ulcers located on the medial malleolus are characteristics of venous insufficiency ulcers

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

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

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

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 55-year-old secretary with a recent history of breast cancer, for which she underwent surgery and radiation therapy, and hypertension comes to the office for a routine check-up. Which of the following aspects of the physical examination are most important when assessing the client for peripheral vascular disease in the arms? a) Femoral pulse, popliteal pulse b) Carotid pulse c) Dorsalis pedis pulse, posterior tibial pulse d) Radial pulse, brachial pulse

Radial pulse, brachial pulse Explanation: These aspects are most important in the physical examination to assess for peripheral vascular disease. This client is at risk for disease in this distribution because of her recent radiation therapy.

The nurse explains to the client with a diagnosis of peripheral vascular disease her is at risk for what occurring? Select all that apply. a) Obesity b) Stroke c) Myocardial infarction d) Diabetes e) Hypertension

Stroke • Myocardial infarction Explanation: Diabetes, hypertension and obesity are risk factors for peripheral arterial disease. Stroke and myocardial infarction are complications that may occur due to peripheral arterial disease.

Which vessels return the lymph fluid to circulation? a) Epitrochlear ducts b) Infraclavicular ducts c) Internal jugular ducts d) Thoracic ducts

Thoracic ducts Explanation: The thoracic ducts at the junctions of the subclavian and internal jugular veins return the lymph fluid to the circulation. There are no internal jugular, epitrochlear, or infraclavicular ducts

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves? a) Allen test b) Trendelenburg test c) Position change test d) Ankle-brachial pressure index (ABPI)

Trendelenburg test Explanation: If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins. The ABPI is considered an accurate objective assessment for determining the degree of peripheral arterial disease. The position change test is done to further assess for arterial insufficiency in the legs following the determination of weak pulses. The Allen test evaluates patency of the radial or ulnar arteries. It is implemented when patency is questionable or before such procedures as a radial artery puncture.

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 a) venous stasis. b) varicose veins. c) arterial insufficiency. d) thrombophlebitis.

arterial insufficiency. 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 nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing a) thrombophlebitis. b) varicose veins. c) edema. d) intermittent claudication.

intermittent claudication 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.

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? a) iliofemoral b) communicating c) saphenous d) popliteal

popliteal Explanation: Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse.

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? a) saphenous b) iliofemoral c) communicating d) popliteal

popliteal Explanation: Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse.

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 a) venous ulcers. b) arterial occlusive disease. c) venous insufficiency. d) 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.

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. a) High-fat diet b) Stress-reduction techniques c) Cigarette smoking d) Previous use of hormones e) Low alcohol intake f) Regular exercise

• High-fat diet • Cigarette smoking • Previous use of hormones 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

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

• Lack of exercise • Smoking • Overweight Correct 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.

Symptoms of complete arterial occlusion include which of the following? Select all that apply. a) Pain b) Color change c) Numbness d) Erythema e) 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.