CH 22 HA PERIPHERAL VASCULAR SYSTEM

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? - "Have you started any new medications?" - "Are you exercising when this occurs?" - "Do you notice your fingers changing colors?" - "Do you have a history of cardiovascular disease?"

"Do you notice your fingers changing colors?" - Numbness, tingling, pain, and burning in the fingertips are findings of Raynaud's disease. Vasospasms or vasoconstriction occur in the fingers or toes and cause rapid changes in the color of the digits (pallor, cyanosis, redness). These vasospasms cause the numbness, tingling, and burning pain

A client diagnosed 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 pain can help us identify what risk factor is predominant." - "The area of pain tells us what treatment will work best for you." - "The area of cramping is close to the area of arterial occlusion." - "The area of cramping indicates whether you may have numbness and tingling also."

"The area of cramping is close to the area of arterial occlusion." - The area of cramping in arterial disease, termed intermittent claudication, closely approximates the level of arterial occlusion. The other options are distracters to the question.

A community health nurse is providing a teaching session on how to reduce the risks of peripheral vascular disease. What should the nurse include in this session? Select all that apply. - Limit the amount of cigarettes smoked daily. - Eat a diet high in raw fruits and vegetables daily. - Participate in regular exercise. - Reduce intake of sodium. - Limit consumption of alcohol to two drinks daily.

- Reduce intake of sodium. - Participate in regular exercise. - Limit consumption of alcohol to two drinks daily - Eat a diet high in raw fruits and vegetables daily. Reducing the risk of arterial disease includes regular daily exercise, a diet high in fruits and vegetables (reduced cholesterol and fats), reduced alcohol intake, and no smoking. Limiting the number of cigarettes smoked in a day will not reduce the risk of peripheral vascular disease. Sodium does play a role in hypertension, which can lead to peripheral vascular disease (PVD), so sodium intake should be limited.

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person? - 0.15 - 0.75 - 0.25 - 1.00

1.00 - The ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABPI of approximately 1.00 or no arterial insufficiency. An ABPI of 0.25 or lower indicates severe stenosis leading to ischemia and tissue damage. An ABPI of 0.5 to 0.95 indicates mild to moderate arterial insufficiency.

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? - Head and neck for recent ear infection or sore throat - Lower arm and hand for erythema and swelling - Cervical lymph nodes for tenderness and swelling - Abdomen, noting any organ enlargement or tenderness

Abdomen, noting any organ enlargement or tenderness - Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area. The epitrochlear nodes are located in the upper inside of the arm. Enlargement of these nodes may indicate infection in the hand or forearm or they may occur with generalized lymphadenopathy. Cervical lymph nodes are part of the system that drains the head and neck, and enlargement would be due to a recent ear infection, sore throat, or other upper respiratory tract infection.

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion? - Allen test - Capillary refill - Ankle brachial index - Valve competency

Allen test - Prior to the cannulation of the radial artery, an Allen test should be performed to assess the patency of collateral circulation. The ankle brachial index is performed on clients with peripheral arterial disease. Valve competency is not tested prior to insertion.

A client at risk for peripheral arterial disease should be screened by which of the following tests? - Bilateral vascular claudication assessment - Angiogram of femoral and popliteal arteries - Ankle-brachial index - Doppler testing of femoral arteries

Ankle-brachial index - The ABI is the primary screening tool used to detect asymptomatic or subclinical PAD.

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 color change test is to check for arterial insufficiency. With the client supine, the legs are elevated about 30 cm (12 in.) above the level of the heart. Then when have the client sit up and dangle the legs. Color should return to the feet and toes within 10 seconds. The superficial veins of the feet fill within 15 seconds. Return of color taking longer than 10 seconds or persistent dependent rubor indicates arterial insufficiency.

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 in active range-of-motion exercise of the upper body. - Assist the client to walk as soon and as often as possible. - Massage lower extremities vigorously every 6 hours. - Raise the foot of the bed for an hour and then lower it

Assist the client to walk as soon and as often as possible - Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation.

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's - popliteal pulse. - femoral pulse. - brachial pulse. - tibial pulse

BRACHIAL PULSE - You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps.

When assessing temperature of the skin, which portion of the hand should the examiner use? - Fingertips - Backs of fingers - Palms - Ulnar aspect of the hand

Backs of fingers - The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. The nurse may have difficulty detecting subtle differences without using the backs of the fingers.

A nurse is caring for a client diagnosed with chronic lymphedema. In preparing a teaching plan for this client, what would be essential for the nurse to address when considering psychosocial wellness? - Body image - Exercise plan - Pathophysiology - Treatment

Body image - Clients with chronic lymphedema may experience disfigurement that affects their body image and self-esteem. It is essential for nurses to address these areas that affect quality of life. Addressing exercise, treatment, and pathophysiology is not considered as essential for the nurse to address in teaching as are body image and self-esteem.

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? - Thigh - Knee - Ankle - Calf

Calf - ain in the calf is the most common site for claudication; however, there could be pain in the buttock, hip, thigh, or foot depending on the level of the obstruction. Absence of this pain does not rule out significant vascular disease, actually, the minority of these clients are symptomatic

The client is experiencing septic shock. What assessment finding would the nurse expect to find? - Blood pressure 128/76 - Warm extremities - Capillary refill greater than 2 seconds - Normal temperature

Capillary refill greater than 2 seconds - The client experiencing septic shock would have a capillary refill greater than 2 seconds. The temperature may or many not be normal, blood pressure would be low and extremities would be cool.

arterial insufficiency

Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs

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? - Lower the legs below heart level. - Observe for gangrene areas. - Assess for diminished pulses. - Elevate the legs on pillows.

Elevate the legs on pillows. - Common complaints of venous ulcer pain include: aching pain and feeling of heaviness which is relieved with elevation of the legs. Relief for arterial ulcer pain is achieved by dependently positioning the legs below the heart. Gangrene and decreased pulses more commonly occur with arterial ulcers; assessing for these symptoms doesn't address the client's pain.

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? - Feel for a pulsation to the fingers in the lower hand - Ask the client to sit on a chair for the examination - Place the second hand 3 to 4 inches above the first hand - Firmly compress the lower portion of the varicose vein

Firmly compress the lower portion of the varicose vein - The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

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 arterial disease. Which of the following is a common symptom that could indicate peripheral arterial disease? - Shortness of breath - Knee pain - Chest pressure with exertion - Intermittent claudication

Intermittent claudication - Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral arterial disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what? - Varicose veins - Pulmonary embolism - Deep vein thrombosis - Intermittent claudication

Intermittent claudication - Pain brought on by exertion and relieved by rest is called intermittent claudication. Varicose veins are due to incompetent valves. Signs of a pulmonary embolus include acute dyspnea, chest pain, tachycardia, diaphoresis, an anxiety. Deep vein thrombosis symptoms include pain, edema, and warmth of an extremity.

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? - Tourniquet should be put on before leg elevation - Ensure that the client's legs are over the side of the bed - Have the client stand upright after tourniquet removal - Legs should be elevated for 15 seconds

Legs should be elevated for 15 seconds - When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.

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? - Have the client sit down - Dorsiflex the client's foot and apply light pressure lateral to and along - the side of the extensor tendon of the big toe - Lightly palpate the client's leg veins for tenderness - Use a Doppler ultrasound device on the client's leg

Lightly palpate the client's leg veins for tenderness - To fully assess for a suspected phlebitis, lightly palpate for tenderness. The client should still be standing from the inspection of the legs. A Doppler ultrasound device is used to assess for pulses when they are difficult to palpate. Dorsiflexing the client's foot and applying light pressure along the extensor tendon of the big toe are done when palpating for the dorsalis pedis pulses.

If palpable, superficial inguinal nodes are expected to be: - Discrete, tender, and 2 cm in diameter - Fixed, tender, and at 2.5 cm in diameter - Fixed, nontender, and 1.5 cm in diameter - Nontender, mobile, and 1 cm in diameter

Nontender, mobile, and 1 cm in diameter

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action? - Assist the client to turn, cough, and deep breathe. - Discontinue the indwelling urinary catheter. - Encourage early ambulation. - Notify the healthcare provider.

Notify the healthcare provider. - The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot.

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 - Ulcer located on medial malleolus - Irregular-shaped ulcer on the inner aspect of the ankle - Reports of aching, cramping pain

Pallor of foot occurs with elevation - Ulcers due to arterial insufficiency would have elevation pallor of the foot due to poor blood supply. Aching and cramping pain is present in ulcers caused by venous insufficiency. Irregular-shaped ulcers and ulcers located on the medial malleolus are characteristics of venous insufficiency ulcers.

The nurse is concerned that a client has poor circulation in the right hand. What finding caused the nurse to have this concern? - Minimal hair on the wrist and fingers - Enlarged epitrochlear lymph nodes - Pallor when the fingers are overextended - Pallor when the ulnar artery is occluded

Pallor when the ulnar artery is occluded - With arterial insufficiency or occlusion of the ulnar artery, pallor persists. This means that there is insufficient radial artery blood flow to the hand. Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm. Hair does not normally grow on the wrist and fingers. Opening the hand into exaggerated extension may cause persistent pallor or a false-positive Allen test.

A nurse palpates a weak left radial artery on a client. What should the nurse do next? - Document the finding in the client's record. - Assess the left hand for pallor and coolness. - Palpate the left ulnar artery. - Palpate both radial arteries for symmetry.

Palpate both radial arteries for symmetry. - Extremities should always be assessed simultaneously for symmetry. If the radial arteries are both weak, this may indicate a problem with peripheral circulation. The nurse should then assess the ulnar artery pulses to determine the presence of arterial insufficiency. The hands should be assessed for pallor and coolness, which would also be present with arterial insufficiency. All findings should be documented in the client's record.

When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause? - Venous insufficiency - Chronic lymphedema - Peripheral arterial disease - Arterial aneurysm

Peripheral arterial disease - Peripheral arterial disease can present with cramping and may result in muscle atrophy. Hypertrophy may result from activity in which the client uses one arm more than the other, such as tennis.

Phlebitis/thrombophlebitis

Prevention: rotate sites every 72-96 hrs; secure catheter; use aseptic technique; for PICCs, avoid excessive activity with the extremity. Treatment: stop infusion; remove peripheral IV catheter; apply HEAT compress; insert new catheter in opposite extremity. edema, throbbing, burning, or pain at site, inc temp, erythema, red line up arm with palpable band at vein site, slowed infusion Treat: D/C infusion and remove IV, elevate extremity, warm compress

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? - If you develop swelling in your ankles or feet, then you should seek emergency care. - Quitting smoking and keeping good control of your blood sugar levels are important. - It's critical that you come to get screening tests twice annually. - I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD.

Quitting smoking and keeping good control of your blood sugar levels are important. - Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests.

A nurse is working with a client who demonstrates venous stasis in his legs. The nurse understands that there must be a problem with one of the mechanisms of venous function that help to propel blood back to the heart. Which of the following are included among these mechanisms? Select all that apply. - Skeletal muscle contraction - Pressure gradient produced by inspiration - Pumping action of the heart - One-way valves in the veins - Gravity

Skeletal muscle contraction Pressure gradient produced by inspiration One-way valves in the veins - Three mechanisms of venous function help to propel blood back to the heart. The first mechanism has to do with the structure of the veins. Deep, superficial, and perforator veins all contain one-way valves. These valves permit blood to pass through them on the way to the heart and prevent blood from returning through them in the opposite direction. The second mechanism is muscular contraction. Skeletal muscles contract with movement and, in effect, squeeze blood toward the heart through the one-way valves. The third mechanism is the creation of a pressure gradient through the act of breathing. Inspiration decreases intrathoracic pressure while increasing abdominal pressure, thus producing a pressure gradient. Veins differ from arteries in that there is no force that propels forward blood flow; the venous system is a low-pressure system. This fact is of special concern in the veins of the leg. Blood from the legs and lower trunk must flow upward with no help from the pumping action of the heart or from gravity.

Which of the following veins drain into the superior vena cava? - Upper torso - Head - Lower extremities - Upper extremities - Lower torso

Upper extremities, Head, Upper torso - The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium. The lower extremities and lower torso drain into the inferior vena cava.

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client? - atherosclerosis - arterial insufficiency - venous insufficiency - deep vein thrombosis

VENOUS INSUFFICENCY - Brownish discoloration just above the malleolus suggests chronic venous insufficiency. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely? - Venous insufficiency - Neuropathic ulcer - Arterial insufficiency - Trauma

Venous insufficiency - These features are most consistent with venous insufficiency. Other findings include scaling, redness, and varicosities. Arterial insufficiency usually affects distal or traumatized areas. Other clues of arterial insufficiency would most likely be present.

When you enter the room of a hospitalized client, you note that the client is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization? - Decreased mobility - Fluid imbalance - Venous thromboembolism - Sepsis

Venous thromboembolism - Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism.

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 - Cold, pale skin on the extremities - Clammy skin on the extremities - Shiny skin, with loss of hair over the lower legs

Warm skin and brown pigmentation around the ankles

Varicosities (varicose veins)

abnormally enlarged, twisted veins can be due to cutting off circulation - Mom has some on ankle

A nurse performs a comprehensive assessment on a new client. The nurse observes the following findings: bilateral lower extremities are cool to touch with sparse hair distribution, legs blanch when raised, and client reports leg pain when walking long distances that resolves with rest. The nurse determines these are signs and symptoms of which of the following disorders? - arterial insufficiency - lymphedema - venous insufficiency - Raynaud's disease

arterial insufficiency - The client is exhibiting signs and symptoms of arterial insufficiency: cool lower extremities, sparse hair distribution, pain when ambulating that resolves with rest (intermittent claudication), and blanching of the legs when raised. Signs and symptoms of venous insufficiency include edema, warm lower extremities, normal pulse, and a feeling of heaviness in the legs. Raynaud's disease affects the fingers and toes. Lymphedema presents with nonpitting edema, affecting one extremity.

Which activities are focused on the assessment of chronic venous insufficiency of the lower extremities? Select all that apply. - assessing for pitting edema - assessing for a history of prolonged standing - assessing for brownish pigmentation of the skin - assessing for a history of incompetent venous system valves - assessing for a history of cirrhosis

assessing for brownish pigmentation of the skin assessing for pitting edema assessing for a history of incompetent venous system valves - When the nurse is assessing for chronic venous insufficiency, findings would indicate edema that is soft, with pitting on pressure, and only occasionally bilateral. There are often brawny changes and skin thickening, especially near the ankle. This condition rises from chronic obstruction and from incompetent valves in the deep venous system. Prolonged standing and liver impairment are associated with pitting edema.

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward? - Radial - Epitrochlear - Ulnar - Brachial

brachial - The brachial pulses are located at approximately the inner third of the antecubital fossa when the palm is held up. It is not usually necessary to palpate the ulnar pulse, which is difficult to locate. The radial pulse site is used when assessing the pulse for vital signs. Epitrochlear is not a term used to identify a pulse.

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the - competence of the saphenous vein valves. - pulse of a client with poor elasticity. - severity of thrombophlebitis. - degree of arterial occlusion that exists.

competence of the saphenous vein valves. - If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins.

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. - rest his arm on the examination table. - assume a supine position. - make a fist with his left hand.

flex his elbow about 90 degrees. - Palpate the epitrochlear lymph nodes. Take the client's left hand in your right hand as if you were shaking hands. Flex the client's elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles. If nodes are detected, evaluate for size, tenderness, and consistency. Repeat palpation on the opposite arm.

intermittent claudication

pain and discomfort in calf muscles while walking but doesn't hurt at rest - a condition seen in peripheral arterial disease

lymohedema

the build-up of fluid in soft body tissues when the lymph system is damaged or blocked.

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing - venous insufficiency. - venous ulcers. - ankle edema. - arterial occlusive disease.

venous insufficiency.