HHA: Chapter 22 Peripheral Vascular System

What pulse is located in the groove between the medial malleolus and the Achilles tendon? -Posterior tibial -Dorsalis pedis -Popliteal -Femoral

-Posterior tibial

When assessing the extremities of a client, the nurse notes muscle atrophy. What does the nurse know may be the cause? -Peripheral arterial disease -Chronic lymphedema -Venous insufficiency -Arterial aneurysm

-Peripheral arterial disease

The nurse assesses the client as shown. What pulse is the nurse assessing? -Femoral -Popliteal -Dorsalis pedis -Posterior tibial

-Posterior tibial

The radial pulse is palpated over the lateral flexor surface. True False

True

Which nursing assessment questions are directed at identifying topics for health counseling for a client diagnosed with arterial disease? Select all that apply. -"How many glasses of liquids do you usually drink each day?" -"Have you had your cholesterol checked recently?" -"Are you currently being treated for hypertension?" -"How much of your day is spent sitting or standing?" -"Do you smoke either cigarettes or cigars?"

-"Have you had your cholesterol checked recently?" -"Are you currently being treated for hypertension?" -"Do you smoke either cigarettes or cigars?"

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

-"The area of cramping is close to the area of arterial occlusion."

Which of the following wounds is most likely attributable to neuropathy? -A painful wound in the client's shin, which is surrounded by apparently healthy skin -A moderately painful wound on the lateral aspect of the client's ankle -A painless wound on the sole of the client's foot, which is surrounded by calloused skin -A wound on a client's highly edematous ankle that is surrounded by pigmented skin

-A painless wound on the sole of the client's foot, which is surrounded by calloused skin

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

-Abdomen, noting any organ enlargement or tenderness

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

-Allen test

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should this client receive? -Risk for peripheral neurovascular dysfunction -Activity intolerance related to pain and claudication with ambulation -Altered tissue perfusion, arterial related to reduced blood flow -Pain related to decreased blood flow and altered tissue perfusion

-Altered tissue perfusion, arterial related to reduced blood flow

What is a long-term complication of peripheral vascular disease? -Metabolic changes -Thickened skin -Amputation -Diabetes mellitus

-Amputation

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? -Venogram -CT scan of the lower legs -Ankle-brachial index (ABI) -PET scan

-Ankle-brachial index (ABI)

During an assessment, the nurse first performs the action shown. 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? -Lymphedema -Femoral pulse -Arterial insufficiency -Intermittent claudication

-Arterial insufficiency

During the physical assessment of the peripheral vascular system, a patient's foot is pale when elevated and dark red when in the dependent position. The nurse is concerned that this patient is at risk for developing: -Neuropathic ulcers -Venous insufficiency ulcers -Arterial insufficiency ulcers -Deep vein thrombosis

-Arterial insufficiency ulcers

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? -Deep vein thrombosis -Arterial occlusion -Pulmonary embolism -Venous thromboembolism

-Arterial occlusion

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding? -Attempt to palpate the posterior tibial pulse. -Assess adequacy of blood flow using a Doppler device. -Check the extremity for findings of decreased blood flow. -Obtain an order for ankle brachial index test to be performed.

-Assess adequacy of blood flow using a Doppler device.

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

-Assist the client to walk as soon and as often as possible.

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

-Backs of fingers

Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a client with aortic regurgitation? -Paradoxical pulse -Bigeminal pulse -Bisferiens pulse -Pulsus alternans

-Bisferiens pulse

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action? -Discontinue the central line. -Culture the tip of the central line. -Flush all ports with heparin solution. -Check the insertion site for redness.

-Check the insertion site for redness.

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply. -Cigarette smoking -Regular exercise -Stress-reduction techniques -Low alcohol intake -Previous use of hormones -High-fat diet

-Cigarette smoking -Previous use of hormones -High-fat diet

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find? -Cold fingers and hands -Cool legs bilaterally -Cool leg on one side -Capillary refill less than 2 seconds

-Cold fingers and hands

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

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 -Bilateral radial pulses of 2+ -Epitrochlear lymph nodes not palpable

-Cool skin

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease? -Diabetes -Lymphedema -Peripheral arterial disease -Venous disease

-Diabetes

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

-Elevate the legs on pillows.

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

-Extent of tobacco use and exposure

Walking contracts the calf muscles and forces blood away from the heart. T or F

-False

Which of the following arteries can be palpated below the inguinal ligament between the anterior superior iliac spine and the symphysis pubis? -Femoral artery -Popliteal artery -Dorsalis pedis artery -artery

-Femoral artery

A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding? -History of Raynaud's disorder -Presence of peripheral artery disease -History of breast surgery -Presence of deep vein thrombosis

-History of breast surgery

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data? -Fear of Loss of Extremity -Impaired Skin Integrity -Risk for Skin Breakdown -Imbalanced Nutrition

-Impaired Skin Integrity

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

-Legs should be elevated for 15 seconds

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 -Use a Doppler ultrasound device on the client's leg -Lightly palpate the client's leg veins for tenderness -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

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

-Nontender, mobile, and 1 cm in diameter

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client? -Advanced chronic arterial occlusive disease -Neuropathy secondary to diabetes -Venous disease -Peripheral arterial disease

-Peripheral arterial disease

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.

The nurse is preparing to conduct a peripheral vascular and lymphatic physical examination of a patient's legs. What instructions should the nurse provide the patient in order to prepare for this examination? (Select all that apply.) -Be aware that the examination can be painful -Remove clothing below the waist. -Lay on your back on a bed or examination table. -Refrain from talking during the examination -Be prepared to lay on your stomach for a portion of the examination.

-Remove clothing below the waist. -Lay on your back on a bed or examination table. -Be prepared to lay on your stomach for a portion of the examination.

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

-Smoking -Overweight -Lack of exercise

What teaching should be included to a client diagnosed with peripheral arterial disease? Select all that apply. -Stop smoking -Low fat diet -Increased activity -Increased fluid intake -Weight management

-Stop smoking -Low fat diet -Increased activity -Weight management

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

-Thin, shiny, atrophic skin

The nurse is preparing discharge teaching for a patient diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include? -How to apply a nonelastic hose -Signs and symptoms of DVT -To avoid sitting for long periods -To walk at least 2 miles/day

-To avoid sitting for long periods

The nurse is preparing discharge teaching for a patient diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include? -How to apply a nonelastic hose -Signs and symptoms of DVT -To avoid sitting for long periods -To walk at least 2 miles/day

-To avoid sitting for long periods Patients with lymphatic disorders have several issues that you must address. As with venous disease, edema in the extremities is the primary symptom of lymphedema. Suggest that the patient avoid sitting or standing for long periods.

Which of the following veins drain into the superior vena cava? (Mark all that apply.) -Lower extremities -Upper torso -Head -Upper extremities -Lower torso

-Upper torso -Head -Upper extremities

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what? -Venous thromboembolism -Arterial occlusion -Neuropathy -Venous obstruction

-Venous thromboembolism

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

-Venous thromboembolism

The posterior tibial pulse can be palpated at the -great toe. -knee. -top of the foot. -ankle.

-ankle.

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing -venous stasis. -varicose veins. -thrombophlebitis. -arterial insufficiency.

-arterial insufficiency.

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

-brachial 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 -degree of arterial occlusion that exists. -pulse of a client with poor elasticity. -competence of the saphenous vein valves. -severity of thrombophlebitis.

-competence of the saphenous vein valves.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder? -deep vein thrombosis -compartment syndrome -acute lymphangitis -acute cellulitis

-deep vein thrombosis

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by -eating a high-protein diet. -resting frequently. -drinking large quantities of milk. -getting regular exercise.

-getting regular exercise.

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. -Raynaud disease. -poor peripheral pulses. -bruits over the radial artery.

-lymphedema.

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? -popliteal -iliofemoral -saphenous -communicating

-popliteal

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 insufficiency

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. -arterial occlusive disease. -venous ulcers. -ankle edema.

-venous insufficiency.

Walking contracts the calf muscles and forces blood away from the heart. True False

False