Health Assessment Ch 18

Ankle-brachial index (ABI)

A nurse is concerned about the client's risk for peripheral vascular disease. Which test is appropriate to order to initially evaluate for this condition?

Cool foot temperature and ulceration on the client's great toe

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Extent of tobacco use and exposure

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

Student compresses the client's nail bed until it blanches.

A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique?

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

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?

Severe stenosis leading to ischemia and tissue damage

A nurse determines that a client's ankle-brachial pressure index (ABPI) is 0.2. Which of the following conditions does this reading indicate?

Assess adequacy of blood flow using a Doppler device.

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?

Lightly palpate the client's leg veins for tenderness

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?

Measure the diameter of the calves

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?

of intermittent claudication

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, because the patient is having symptoms

Disturbed Body Image related to edema, legs ulcerations or varicosities as evidenced by embarressment

A 64 y/o women is admitted to the hospital. She is very embarrassed about large varicose veins in the calf and thigh of both legs. The patient does not want the nurse to look at her legs. The most appropriate nursing diagnosis would be

It filters harmful substances from the body.

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

Warm skin and brown pigmentation around the ankles

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

Peripheral vascular problems

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?

Upper abdomen

A group of students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes?

Examine the lower arm and hand for infection sites.

A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next?

A painless wound on the sole of the client's foot, which is surrounded by calloused skin

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

popliteal

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded?

brachial pulse

After palpating the radial pulse of an adult patient, the nurse suspects arterial insufficiency. The nurse should next assess the patient's

Arterial insufficiency

An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect?

Compare measurements of both extremities.

Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next?

4+

Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as?

Thoracic ducts

Which vessels return the lymph fluid to circulation?

insufficiency

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 venous

Femoral

During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse?

Arteries carry oxygen rich blood. Veins carry deoxygenated, waste laden blood

During an assessment, a patient says "I know that arteries and veins are blood vessels, but what is the difference?" Which of the following would the nurse include in the response?

Diabetes

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?

Arterial insufficiency ulcers

During the physical assessment of the peripheral vascular system, a patient's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this patient is at risk for developing:

• Smoking • Lack of exercise • Overweight

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk?

pitting

If edema is noted during inspection, palpate the area to determine if is is pitting or nonpitting. Press the edematous area with the tip of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented what type of edema is present?

Nontender, mobile, and 1 cm in diameter

If palpable, superficial inguinal nodes are expected to be:

• Color change • Pain • Numbness

Symptoms of complete arterial occlusion include which of the following?

Arterial occlusion

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?

• Obstructive airway disease • Pericardial tamponade • Possible constrictive pericarditis

The client has a difference between the highest and lowest systolic pressure of 12 mm Hg. What does this indicate?

Check feet daily for cuts or pressure areas.

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?

brachial artery.

The major artery that supplies blood to the arm is the

brisk, expected (normal) pulse

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

use a Doppler ultrasound

The nurse is assessing the dosalis pedis pulse on a patient using her fingertips. The nurse is not able to feel the pulse. What device would the nurse use to determine if there is blood flow at the dorsales pedis pulse?

Intermittent claudication

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

getting regular exercise.

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by

"Quitting smoking and keeping good control of your blood sugar levels are important."

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?

to venous insufficiency

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation related

a superficial thrombophlebitis

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

The client's toe is receiving an inadequate supply of blood.

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

lateral flexor surface.

The radial pulse is palpated over the

Amputation

What is a long-term complication of peripheral vascular disease?

Cigarette smoking

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

14-year history of smoking a pack a day

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

Have the client stand for the exam.

When assessing a client for possible varicose veins, the nurse should do which of the following actions?

malignancy

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with

have arterial insufficiency

While assessing the peripheral vascular system of an adult patient, the nurse detects cold clammy skin and loss of hair on the patient's legs. The nurse suspects that the patient may

Venous insufficiency

While inspecting the skin color of a male client's legs, the nruse observes that the client's legs are slightly cyanotic while he is sitting on the edge of the examination table. The nurse should refer the client to a physician for possible

Thin, shiny, atrophic skin

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?

Lower arm and hand for erythema and swelling

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?

• Hypertension • Smoking • Family history

The nurse is discussing risk factors of an aneurysm. What should be included?

1.1

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

Palpate the brachial pulse.

A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most appropriate action?

Ulnar

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

Document the lack of patency in the ulnar and/or radial arteries.

The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test?

Immobility

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?

Elevate the legs on pillows.

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?

• Remove clothing below the waist. • Lay on your back on a bed or examination table. • Be prepared to lay on your stomach for a portion of the examination.

The nurse is preparing to conduct a peripheral vascular and lymphatic physical examination of a patient's legs. What instructions should the nurse provide the patient in order to prepare for this examination?

flex her elbow about 90 degress.

The nurse is preparing to palpate the epitrochlear lymph nodes of an adult patient. The nurse should instruct the patient to

Behind the ankle

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

on the inside of the ankle just below the medial malleolus

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

Apply K-Y jelly to the client's skin

The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. The nurse should

0.50

A nurse obtains the following information: right arm brachial pressure, 160 mm Hg; left arm brachial pressure, 150 mm Hg; right ankle pressure, 80 mm Hg; left ankle pressure, 94 mm Hg. The nurse determines that the right ankle-brachial index would be which of the following?

Abdomen, noting any organ enlargement or tenderness

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?

Right 0.53; Left 0.56

A nurse performs an ankle-brachial pressure index (ABPI) and obtains these results: R arm Blood Pressure 140/90 mm Hg, L arm Blood Pressure 150/90 mm Hg; R ankle 80 mm Hg, L ankle 85 mm Hg. Determine the right and left ABPI.

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

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?

lymphedema

A pateint visits the clinical and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the patient for

Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger

Which area of the arm drains to the epitrochlear nodes?

Femoral artery

Which of the following arteries can be palpated below the inguinal ligament between the anterior superior iliac spine and the symphysis pubis?