Peripheral Vascular PrepU/ Sakai Quiz
A client with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?
"The area of cramping is close to the area of arterial occlusion."
When assessing Mr. V, the nurse documents the amplitude of the left femoral pulse as "0." Which of the following findings would the nurse expect of the left dorsalis pedis pulse?
0
An ABPI of ___ or lower indicates severe stenosis leading to ischemia and tissue damage.
0.25
An ABPI of ___ to ___ indicates mild to moderate arterial insufficiency.
0.5 to 0.9
The ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABPI of approximately ___ or no arterial insufficiency.
1.00
The ______ is used to evaluate the patency of the radial or ulnar arteries.
Allen's Test
Which of the following situations best describes a person at risk for developing a deep vein thrombosis (DVT)? a. A person with a 30-year, 1PPD smoking history b. An elderly person taking anticoagulant medication c. An individual who has been hospitalized and on bedrest for 3 days d. A patient that needs assistance to get out of bed
An individual who has been hospitalized and on bedrest for 3 days
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)
An Allen's test is performed to determine whether there is a problem with which of the following?
Arterial Insufficiency
_____ are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system; walls are thick and strong and contain elastic fibers for stretching.
Arteries
The ____ artery divides near the elbow into the radial and ulnar arteries.
Brachial
The ____ pulses are located at approximately the inner third of the antecubital fossa when the palm is held up.
Brachial
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
Which pulse is at the antecubital crease
Brachial pulse
Which of the following forces fluid out of the capillaries into the interstitial tissue?
Capillary hydrostatic pressure
If a pulse cannot be palpated, the nurse's best action is to obtain a ____ device to assess for adequate blood flow.
Doppler
Which pulse is Just lateral to the prominent extensor tendon of the big toe
Dorsalis pedis pulse
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 legs?
Femoral artery
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
53 year old Bette comes to the clinic complaining of right upper extremity swelling following a right mastectomy (the removal of breast tissue & lymph nodes) because of breast cancer. What is the MOST likely cause of her swelling?
Lymphedema
Which pulse is In the groove between the medial malleolus and the achilles tendon
Posterior tibial pulse
The ____ pulse is palpated over the lateral flexor surface.
Radial
The ____ pulse site is used when assessing the pulse for vital signs.
Radial
Which pulse is at the Lateral aspect (thumb side) of the inner wrist
Radial pulse
By the retrograde filling (_______) test, you can assess the valvular competency in both the communicating veins and the saphenous system.
Trendelenburg
T/F Checking for varicosities and palpating the femoral pulses are routine parts of the exam and unrelated to the assessment findings
True
T/F The mild to moderate disease is represented by an ABI of 0.5 to 1.0. Severe disease is defined as 0.5 or less.
True
T/F the vessel walls of veins are thinner than those of arteries
True
A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area?
Upper arm (3 cm above elbow on the inner aspect of the arm)
_____ contain nearly 70% of the body's blood volume.
Veins
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:
arterial insufficiency, venous insufficiency, diminished sensation in pressure points
Hypertension can lead to _____ _____ not ulcers
arterial insufficiency; aethersclerosis
The axillary lymph nodes would be palpated in the ____ area.
axillary
Occlusion meaning
blockage
Pain in the ____ is the most common site for claudication (obstruction of arteries)
calf
Arterial insufficiency causes a _____ in the amount of blood flow to an extremity. Which can cause pulse to _____ or _____
decrease, decrease, diminish
The nurse is palpating 71 year old Mr. Clark's lower extremities and notes that the left lower extremity feels cooler than the right lower extremity. What does the nurse suspect?
decreased arterial blood flow
With venous insufficiency, _____ would most likely be noted. Also brown-pigmented thickened skin.
edema
When would the nurse use a doppler ultrasound device to evaluate a patient's lower extremity pulses?
if the pulses are not palpable
What helps veins propel blood back to the heart?
intraluminal valves, muscular contraction, abdominal/intrathoracic pressure
The superficial inguinal nodes drain the...
legs, external genitalia, lower abdomen, and buttocks
The posterior cervical and occipital nodes would be palpated on the posterior aspect of the _____.
neck
Claudication meaning
pain in arm or leg caused by blocked arteries
Which of the following findings signifies adequate blood flow? a. A.capillary refill of 5 seconds b. pulse amplitude is +2 c. skin is cool to touch d. no edema present
pulse amplitude is +2
It is documented on 83 year old Mrs. Juno's chart that she has a venous ulcer on her left ankle. What does the nurse expect that the ulcer will look like?
red granulation tissue, uneven edges and may bleed
Arterial insufficiency signs and symptoms
thin, shiny, atrophic, cool, pale skin. delayed capillary refill, absence of pulses, loss of hair, thick rigid nails. Pain, muscle cramping, and weakness with activity, relief with rest.
T/F The lymphatic system prevents edema by draining excess fluids and proteins from the tissues.
true
Absence of this pain does not rule out significant ____ _____—actually, the minority of these clients are symptomatic.
vascular disease
Edema and brown-pigmented thickened skin are associated with
venous insufficiency
