HA Chapter 15: The Peripheral Vascular System and Lymphatic System

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. I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD. It's critical that you come to get screening tests twice annually.

"Quitting smoking and keeping good control of your blood sugar levels are important." Explanation: 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. Pg. 464

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

1.00 Explanation: 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. Pg. 460

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 Sedentary lifestyle A family history of arterial insufficiency Intake of 1 to 2 alcoholic drinks per day

14-year history of smoking a pack a day Explanation: The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and amount of tobacco smoked. Factors such as lack of exercise, family history, and alcohol intake may be relevant, but smoking is the most significant risk factor. Pg. 500

Which of the following clients is most likely at the greatest risk of acute compartment syndrome?

A 17-year-old who has just been fitted with an arm cast following a fracture of his radius Explanation: Application of a cast that is too tight is a central risk factor for the development of compartment syndrome. Pg. 466

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. Explanation: A painless wound on the sole of the client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.

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) Explanation: The ABI is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Approximately 16% of clients with known peripheral vascular disease also have coronary artery disease. Pg. 460

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 Explanation: Cool, pale skin, delayed capillary refill, and absence of pulses are associated with arterial insufficiency. Pg. 452 468

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 Explanation: Symptoms of a complete arterial occlusion includes pain, numbness, coolness, or color change of an extremity and is an emergency. A deep vein thrombosis is characterized by pain, edema and warmth of the extremity. Pulmonary embolism symptoms include acute dyspnea, chest pain, diaphoresis and anxiety. Pg. 466

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. Explanation: Arteries are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system. Arterial walls are thick and strong and contain elastic fibers for stretching. Pg. 439

A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse?

Assist the client to the prone position and palpate again If the nurse is unable to palpate the popliteal artery with the client in supine position, the nurse should assist the client to prone position and palpate again. If the nurse is still unable to palpate, a Doppler should be used. The nurse may partially raise the client's leg and place the fingers deep in the bend of the knee when in prone position, not in supine position. Pg. 455

When assessing temperature of the skin, which portion of the hand should the examiner use?

Backs of fingers Explanation: 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. Pg. 450

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

Capillary refill greater than 2 seconds Explanation: 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. Pg.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check the insertion site for redness. Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip. Pg. 454

Which of the following assessment findings is most congruent with chronic arterial insufficiency? Thickened and scarred skin on the client's ankle Brown pigmentation around a client's ankles and shins Ulceration on the medial surface of the client's ankle Cool foot temperature and ulceration on the client's great toe

Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency? Cool skin Capillary refill time of 2 seconds Epitrochlear lymph nodes not palpable Bilateral radial pulses of 2+

Correct response: Cool skin Explanation: A cool extremity may be a sign of arterial insufficiency. The other findings listed are all normal. Pg. 457

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

Correct response: Legs should be elevated for 15 seconds Explanation: 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. Pg. 467

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Correct response: Notify the healthcare provider. Explanation: 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. Pg. 452

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? Prevention of varicose veins Significance of cardiac dysrhythmias Extent of tobacco use and exposure Exercise tolerance

Extent of tobacco use and exposure Explanation: Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias.

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

Have the client stand for the exam. Explanation: When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting.

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?

Intermittent claudication Explanation: Pain brought on by exertion and relieved by rest is called intermittent claudication. Pg. 466

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply. Lack of exercise Family history Smoking Ethnicity Overweight

Lack of exercise Smoking Overweight Explanation: Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors. Pg. 464

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Normal finding Explanation: Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less.

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 Explanation: With arterial insufficiency or occlusion of the ulnar artery, pallor persists. This means that there is insufficient radial artery blood flow to the hand. Pg. 458

A nurse palpates a weak left radial artery on a client. What should the nurse do next?

Palpate both radial arteries for symmetry. Explanation: 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. Pg. 450

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

Palpate the brachial pulse. Explanation: When unable to palpate a peripheral pulse, the pulse area immediately proximal to it should be palpated. In this case, the brachial pulse is indicated. Inability to palpate the client's pulses suggests arterial insufficiency.

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

Popliteal artery Explanation: Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse Pg. 462

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? Normal temperature Normal pulsation Thin, shiny, atrophic skin Marked edema

Thin, shiny, atrophic skin Explanation: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened. Pg. 464

T/F The radial pulse is palpated over the lateral flexor surface.

True

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 Explanation: A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable. The nurse would need to attempt to assess the pulse, and if the pulse could not be obtained via Doppler, then it would be appropriate to document the absence of the pulse and include attempts to assess it, such as via palpation and Doppler ultrasound.

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 Explanation: A rusty or brownish pigmentation around the ankles indicates venous insufficiency.

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 Explanation: Venous insufficiency is characterized by aching, cramping, pigment changes. If the client has an ulcer, it will be painful. Arterial insufficiency is characterized by decreased pulses, dry, shiny, cold skin. Intermittent claudication is pain brought on by exertion and relieved by rest. Hypertrophic changes include a loss of hair and pallor. Pg. 452

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 Explanation: Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Pg. 470

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 Explanation: The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct. Pg. 443

The presence of faint pedal pulses in a client has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client may have arterial insufficiency?

the client's legs are visibly pale when elevated above the examination table Explanation: Marked pallor with legs elevated during the position change test is an indication of arterial insufficiency. A return to pink color should take place in less than 10 seconds. The position change test does not assess for signs of venous insufficiency such as edema. Pain is not assessed during the position change test. Pg. 467

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 Explanation: Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. 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. Pg. 452

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 Explanation: Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus. Pg. 468