Jensen - Ch. 18

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?

14-year history of smoking a pack a day

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

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

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?

Abdomen, noting any organ enlargement or tenderness

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

Amputation

The nursing instructor is discussing the great and small saphenous veins. What would the instructor say connects these two veins?

Anastomotic veins

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?

Ankle-brachial index (ABI)

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?

Arterial occlusion

During a health visit, a client says, "I know that arteries and veins are blood vessels, but what's the difference?" Which of the following would the nurse include in the response?

Arteries have thicker walls than veins.

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 a Doppler device.

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.

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?

Compare measurements of both extremities.

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. What would the nurse do next?

Compare measurements of both extremities.

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:

Hypertension

The nurse is discussing risk factors of an aneurysm. What should be included? Select all that apply.

Hypertension Smoking Family history

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?

Immobility

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?

It filters harmful substances from the body.

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 performs the Trendelenburg test for a client with varicose veins. What care 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

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?

Lymphedema

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

Measure the diameter of the calves.

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

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

The nurse is concerned that a client has poor circulation in the right hand. What finding caused the nurse to have this concern?

Pallor when the ulnar artery is occluded

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

Palpate the brachial pulse.

The six Ps of peripheral arterial occlusion include which of the following?

Paresthesia

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

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

A nurse experiences difficulty in palpating the popliteal pulses in a client during assessment of the peripheral vascular system. What should the nurse do to assist in locating this pulse on a client?

Place the client in the prone position.

A nurse asks a supine client to raise his knee partially. The nurse then 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 determines that a client's ankle-brachial pressure index (ABPI) is 0.2. Which of the following conditions does this reading indicate?

Severe stenosis leading to ischemia and tissue damage

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 colour

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply.

Skeletal muscle contraction Respiration Intraluminal valves

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

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

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

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?

Student compresses the client's nail bed until it blanches. Document the lack of patency in the ulnar and/or radial arteries.

The nurse assessing the client's skin identifies an ulcer. What would indicate to the nurse it is a venous ulcer?

The ulcer is superficial and pale.

A group of nursing 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?

Upper abdomen

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?

Use Doppler ultrasonography to locate the pulse.

What should a nurse do if a posterior tibial pulse cannot be obtained on a client with edema of the feet?

Use a Doppler to assess for the presence of the pulse.

The posterior tibial pulse can be palpated at the

ankle.

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

apply K-Y jelly to the client's skin.

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

arterial insufficiency.

Which activities are focused on the assessment of chronic venous insufficiency of the lower extremities? Select all that apply.

assessing for brownish pigmentation of the skin assessing for pitting edema assessing for a history of incompetent venous system valves

The major artery that supplies blood to the arm is the

brachial artery.

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

brisk, expected (normal) pulse

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis

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

flex his elbow about 90 degrees.

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?

right cervical node

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

venous insufficiency

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which statement would the nurse include in the response?

"Arteries have thicker walls than veins."

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?"

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?

Arterial insufficiency

An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect?

Arterial insufficiency

During an assessment, the nurse first performs the action shown. After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

Arterial insufficiency

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

Behind the ankle

When describing the major arteries of the arms and legs, which of the following would the instructor identify as the major supplier of blood to the arms?

Brachial artery

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?

Calf

The nurse assesses a client's hand as shown. What is the nurse assessing?

Capillary refill

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?

Cigarette smoking

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

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

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

Cool skin

A 72-year-old retired teacher comes to the clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes are risk factors for peripheral vascular disease?

Coronary artery disease

The nurse palpates the top of the client's foot on the side of the great toe. Which artery is the nurse palpating?

Dorsalis pedis

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. What should the nurse do next?

Document this finding as normal.

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following would the nurse do next?

Document this finding as normal.

While completing the past history of a patient's peripheral vascular and lymphatic systems, the nurse is concerned that the patient is at risk for peripheral vascular disorders. What assessment data would cause the nurse to arrive at this conclusion? (Select all that apply.)

Currently smokes one pack per day Body mass index 30

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

Deep ulcers that often involve joint space

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.

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?

Elevate the legs on pillows.

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

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

Extent of tobacco use and exposure

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?

Femoral

The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse?

Femoral

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

Femoral artery

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?

Firmly compress the lower portion of the varicose vein.

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

Have the client stand for the exam

The nurse is assessing a client for varicose veins. Which action, by the nurse is appropriate?

Have the client stand for the exam.

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 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?

Impaired Skin Integrity

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?

Intermittent claudication

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?

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

A client seeks medical attention for the condition shown. What finding does the nurse anticipate?

Raynaud's disease

The nurse assesses the client as shown. What pulse is the nurse assessing?

Posterior tibial

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?

Thin, shiny, atrophic skin

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

The radial pulse is palpated over the lateral flexor surface.

True

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?

Ulnar

A nurse prepares to perform the manual compression test on a client with which of the following?

Varicose veins

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?

Venous insufficiency

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?

Venous insufficiency

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Venous insufficiency

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?

Venous insufficiency

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

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

getting regular exercise.

The popliteal artery can be palpated at the

knee.

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.

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

popliteal