Health Assessment: Chapter 20: Peripheral Vascular and Lymphatic System

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: a. Claudication. b. Sore muscles. c. Muscle cramps. d. Venous insufficiency.

A Intermittent claudication feels like a cramp and is usually relieved by rest within 2 minutes. The other responses are not correct.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg

A, D, E Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.

Which vein(s) is(are) responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial

D The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

A Blood moves through the veins by (1) contracting skeletal muscles that proximally milk the blood; (2) pressure gradients caused by breathing, during which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema

A If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: a. Nonpitting, hard edema occurs with lymphatic obstruction. b. Alterations in arterial function will cause edema. c. Phlebitis of a superficial vein will cause bilateral edema. d. Long-standing arterial obstruction will cause pitting edema.

A Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema)

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day.

A, B, E Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset with exertion and is relieved with rest or dangling. The skin appears cool and pale (see Table 20-3). The other responses reflect chronic venous problems

When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? a. Document the finding. b. Auscultate the site for a bruit. c. Check for calf pain. d. Check capillary refill in the toes.

B If a pulse is weak or diminished at the femoral site, then the nurse should auscultate for a bruit. The presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct

During an assessment, the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be: a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position.

B In this test, it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Significant elevational pallor, as well as delayed venous filling, occurs with arterial insufficiency

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? a. Excessive swelling of the lymph nodes b. Presence of palpable lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult

B Lymph nodes are relatively large in children, and the superficial ones are often palpable even when the child is healthy.

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? a. Venous stasis b. Lymphedema c. Arteriosclerosis d. Deep-vein thrombosis

B Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and lymphedema can impede drainage of lymph. The other responses are not correct.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing: a. Pain related to lymphatic abnormalities. b. Problems related to arterial insufficiency. c. Problems related to venous insufficiency. d. Pain related to musculoskeletal abnormalities.

B Night leg pain is common in aging adults and may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication

B People who undergo prolonged standing, sitting, or bed rest are at risk for venous disease. Hypercoagulable (not anticoagulated) states and vein-wall trauma also place the person at risk for venous disease. Obesity and the late months of pregnancy are also risk factors

During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? a. Deep-vein thrombophlebitis b. Varicose veins c. Lymphedema d. Raynaud phenomenon

B Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are observed on assessment. (See Table 20-5 for the description of deep-vein thrombophlebitis. See Table 20-2 for descriptions of Raynaud phenomenon and lymphedema.)

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: a. Lymphedema. b. Raynaud disease. c. Deep-vein thrombosis. d. Chronic arterial insufficiency.

B The condition with episodes of abrupt, progressive tricolor changes of the fingers in response to cold, vibration, or stress is known as Raynaud disease. (Lymphedema is described in Table 20-2; deep-vein thrombosis is described in Table 20-5; and chronic arterial insufficiency is described in Table 20-4.)

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? a. "Lymph flow is propelled by the contraction of the heart." b. "The flow of lymph is slow, compared with that of the blood." c. "One of the functions of the lymph is to absorb lipids from the biliary tract." d. "Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream."

B The flow of lymph is slow, compared with flow of the blood. Lymph flow is not propelled by the heart but rather by contracting skeletal muscles, pressure changes secondary to breathing, and contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves; therefore, flow is one way from the tissue spaces to the bloodstream.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region

B The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender

During an assessment, the nurse uses the profile sign to detect: a. Pitting edema. b. Early clubbing. c. Symmetry of the fingers. d. Insufficient capillary refill.

B The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

Which statement is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase.

B The pumping heart makes the arterial system a high-pressure system.

The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.

B To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? a. Bounding b. Normal c. Weak d. Absent

B When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse. a. Normal b. Absent c. Bounding d. Weak, thready

C A full, bounding pulse occurs with hyperkinetic states (e.g., exercise, anxiety, fever), anemia, and hyperthyroidism. An absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

C A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? a. "Is easily palpable; pounds under the fingertips." b. "Has greater than normal force, then suddenly collapses." c. "Is hard to palpate, may fade in and out, and is easily obliterated by pressure." d. "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

C A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.

C Arterial ischemic ulcers occur at the toes, metatarsal heads, heels, and lateral ankle and are characterized by a pale ischemic base, well-defined edges, and no bleeding. (See Table 20-5 for a description of varicose veins and deep-vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.)

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying

C Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.

C Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient? a. Enlarged, warm, and tender nodes b. Lymphadenopathy of the cervical nodes c. Palpable firm, small, shotty, mobile, and nontender lymph nodes d. Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue

C Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, and tender nodes indicate a current infection.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should: a. Check for the presence of claudication. b. Refer the individual for further evaluation. c. Consider this finding as normal, and proceed with the peripheral vascular evaluation. d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

C Palpating the ulnar pulses is not usually necessary. The ulnar pulses are not often palpable in the normal person. The other responses are not correct.

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

C Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. a. Ulnar b. Radial c. Brachial d. Deep palmar

C The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Regular "lub, dub" pattern c. Swishing, whooshing sound d. Steady, even, flowing sound

C When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg

D A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems

When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: a. Are often associated with venous disease. b. Occur in the presence of lymphadenopathy. c. In the femoral arteries are caused by hypermetabolic states. d. Occur with turbulent blood flow, indicating partial occlusion.

D A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when this vein is removed?" The nurse should reply: a. "Venous insufficiency is a common problem after this type of surgery." b. "Oh, you have lots of veins—you won't even notice that it has been removed." c. "You will probably experience decreased circulation after the vein is removed." d. "This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition."

D As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming circulation. The other responses are not correct.

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: a. Alternans. b. Bisferiens. c. Bigeminus. d. Paradoxus.

D In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration and is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe

D The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patient's abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

D The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a. Normal ABI indices are from 0.5 to 1.0. b. Normal ankle pressure is slightly lower than the brachial pressure. c. The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes. d. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.

D Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a false high-ankle pressure.