Health Assessment Peripheral Vascular and Lymph System
c
A 42-year-old woman reveals an intake of medications. Which medication if reported by the client would alert the nurse to the need to assess the client for thrombophlebitis? A) Antihypertensive B) Antidepressant C) Oral contraceptive D) Antilipid agent
a
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? A) It filters harmful substances from the body. B) It produces protective antibodies. C) It manufactures T lymphocytes. D) It drains capillary blood from the circulation.
d
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? A) Legs B) External genitalia C) Upper abdomen D) Buttocks
a
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? A) Document this finding as normal. B) Recheck in 5 minutes after elevating the arm. C) Reassess after applying warm compresses. D) Refer the client for medical follow-up.
c
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) Ask the client about any recent ear and throat infections. B) Carefully assess the cervical lymph nodes for enlargement. C) Examine the lower arm and hand for infection sites. D) Assess both legs for Homans' sign.
d
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? A) 0.5 B) 0.7 C) 0.9 D) 1.1
b
A nurse is having difficulty palpating the femoral pulse on an adult client. Which of the following would be most appropriate for the nurse to do? A) Ask another nurse to assess the pulse. B) Listen for femoral bruits. C) Perform the Allen's test. D) Assess the popliteal pulse.
d
A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) Posterior neck B) Axillary area C) Inguinal area D) Upper arm
c
A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next? A) Refer the client for medical follow-up. B) Document the finding. C) Palpate the brachial pulse. D) Auscultate the apical pulse.
a
A nurse obtains the following information: right arm brachial pressure, 160; left arm brachial pressure, 150; right ankle pressure, 80; left ankle pressure, 94. The nurse determines that the right ankle-brachial index would be which of the following? A) 0.50 B) 0.53 C) 0.59 D) 0.63
c
A nurse prepares to perform the manual compression test on a client with which of the following? A) Venous ulcer B) Arterial occlusion C) Varicose veins D) Lymphedema
b
An instructor is observing a student assess a client's capillary refill. Which action by the student indicates the proper technique? A) Student gently compresses the wrist area on the side of the thumb B) Student compresses the client's nailbed until it blanches C) Student applies firm pressure to the hand, noting any indentation D) Student asks client to turn hands slowly over and back
a
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? A) Arterial insufficiency B) Musculoskeletal weakness C) Venous insufficiency D) Neurologic impairment
a
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? A) Compare measurements of both extremities. B) Perform the Allen's test C) Check for bilateral varicosities. D) Palpate the femoral pulses.
b
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 which of the following? A) 1+ B) 2+ C) 3+ D) 4+
a
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? A) Arteries have thicker walls than veins. B) Arteries carry 70% of the body's blood volume. C) Arteries have a lower pressure than veins. D) Arteries carry waste from the tissues.
d
The nurse determines that a client's edema of the lower extremities is most likely due to lymphedema based on which of the following? A) Pitting edema B) Ulceration of the skin C) Areas of pigmentation D) Bilaterally present
d
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect? A) Arterial occlusion B) Venous insufficiency C) Varicose veins D) Thrombophlebitis
d
The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate? A) Just behind the knee B) At the top of the foot C) In the groin area D) Behind the ankle
c
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next? A) Document "absence of dorsalis pedis pulse." B) Auscultate the anatomic area with a stethoscope. C) Use Doppler ultrasonography to locate the pulse. D) Ask another nurse to assess the pulse.
d
The nurse measures the circumference of a client's arms because of lymphedema in the right arm. The nurse obtains a difference of 6 cm between the right and left arms. The nurse would document this finding as which state of lymphedema? A) 0 B) I C) II D) III
a
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? A) Venous insufficiency B) Stasis ulceration C) Arterial occlusion D) Dependent edema
d
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? A) Participation in daily exercise B) A family history of arterial insufficiency C) Intake of 2 beers per week D) Cigarette smoking
a
When assessing a client for possible varicose veins, which of the following would the nurse do? A) Have the client stand for the exam B) Tell the client to raise his or her leg C) Dorsiflex the client's foot D) Obtain the ankle-brachial index
c
When describing fluid exchange and the capillaries, the instructor explains which mechanism as the most likely cause if oxygen, water, and nutrients are having difficulty entering the interstitial fluid? A) Osmotic pressure B) Gravitational flow C) Hydrostatic force D) Diastolic pressure
b
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? A) Radial artery B) Brachial artery C) Femoral artery D) Ulnar artery
c
When reviewing the adult circulation, the nurse understands that which mechanism primarily aids in returning blood to the heart?? A) Pressure gradients B) Gravitational flow C) Muscular contractions D) Heart muscle contraction
c
Which question would be most important to ask obtaining the nursing health history of a male client with extensive peripheral vascular disease? A) "Do your parents have trouble with circulation?" B) "When was your last prostate exam for cancer?" C) "Have you experienced a change in your usual sexual activity?" D) "Have you had an electrocardiogram recently?"
b c e
While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. A) Irregular border B) Deep C) Circular in shape D) Moderate leg edema E) Client report of severe pain
