Chapter 22: Assessing the 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 notice your fingers changing colors?"

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

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.

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

A nurse is working with a client who demonstrates venous stasis in his legs. The nurse understands that there must be a problem with one of the mechanisms of venous function that help to propel blood back to the heart. Which of the following are included among these mechanisms? Select all that apply.

-One-way valves in the veins -Skeletal muscle contraction -Pressure gradient produced by inspiration

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.

-Traps and destroys microorganisms and foreign materials filtered from lymph -Absorbs fats from the small intestine into the bloodstream -Drains excess fluid and plasma proteins from tissues and returns then to the venous system

Which reading of the ankle-brachial pressure index (ABI) should the nurse recognize as indicative of a normal healthy person?

1.00

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?

3+

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?

Assess adequacy of blood flow using Doppler device

A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse?

Assist the client to the prone position and palpate again

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?

Assist the client to walk as soon and as often as possible

A client with peripheral vascular disease is discharged from the health care facility. Which risk-reduction teaching tip should the nurse discuss during discharge teaching?

Avoid smoking

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

Cook skin

A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency?

Deep ulcers that often involve joint space

On questioning a client with peripheral edema during an interview, the nurse learns that the client has a sedentary job and drinks little water throughout the day. What underlying condition is the client most likely to have, based on these findings?

Deep vein thrombosis

A nurse assesses capillary refill time in a client and finds it to be less than 2 seconds. What is an appropriate action by the nurse?

Document the finding as normal

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?

Elevate the legs and observe for the onset of pallor

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?

Ensure that the client's hand is not opened in exaggerated extension

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 breast surgery

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

Impaired skin integrity

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

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?

Lightly palpate the client's leg veins for tenderness

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?

Lower arm and hand for erythema and swelling

A nurse recognizes that what change is considered normal in the lymphatic system of the elderly?

Lymph nodes are smaller and fewer in number

Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results?

Make sure the temperature in the room is comfortable

A nurse inspects the lower extremities of a client and notices that the legs appear asymmetric. What should the nurse do first in regards to this finding?

Measure the diameter of the calves

A nurse assists the client to perform the position change test for arterial insufficiency. While the client is dangling the legs, the nurse observes a return of color to the feet in 8 seconds. How should the nurse document the finding for this test?

Normal (Less than 10 seconds)

A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding?

Pain in the calf muscles

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?

Pallor of foot occurs with elevation

A nurse palpates a weak left artery on a client. What should the nurse do next?

Palpate both radial arteries for symmetry

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?

Peripheral arterial 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?

Peripheral vascular problems

A nurse asks a supine client to raise his knee partially. The nurse ten places the thumbs on the knee while positioning the fingers deep in the bend of the knee. The nurse is palpating the pulse of which artery?

Popliteal

A nurse performs an ankle-brachial pressure index and obtains these results: R arm BP 140/90, L arm BP 150/90, R ankle 80, L ankle 85. Determine the right and left ABPI.

R .53, L .56 Divide highest brachia pressure by each arm number. 80/150 and 85/150

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?

Trendelenburg test

Which statement describes the correct technique by a nurse when performing the ankle-brachial pressure index test?

Use a blood pressure cuff that is 20% wider than the diameter of the client's limb

A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?

Warm skin and brown pigmentation around the ankles

Which statement demonstrates correct technique by a nurse when using the Doppler device to locate the peripheral pulses?

Warming the gel will help to avoid vasoconstriction at the site