Ch. 18 Peripheral Vascular with Lymphatics

The popliteal artery can be palpated at the Inguinal ligament. Knee. Ankle. Great toe.

Knee. The popliteal pulse can be palpated behind the knee. The popliteal artery divides below the knee into anterior and posterior branches.

The six Ps of peripheral arterial occlusion include which of the following? Paresthesia Piloerection Pilocarpine Pilonidal

Paresthesia

When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for x arterial insufficiency? A family history of arterial insufficiency Sedentary lifestyle Intake of 1 to 2 alcoholic drinks per day 14-year history of smoking a pack a day

14-year history of smoking a pack a day 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.

During an assessment, the nurse first performs the action shown (patient is laying supine, legs held up 45° by examiner). 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 Lymphedema Femoral pulse Intermittent claudication

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. This is not a technique to assess lymphedema, the femoral pulse, or intermittent claudication.

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 Venous thromboembolism Arterial occlusion Pulmonary embolism

Arterial occlusion 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. Venous thromboembolism occurs when a blood clot travels from the legs to the lungs.

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 the client to walk as soon and as often as possible. 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. 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. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

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? Intake of 2 beers per week A family history of arterial insufficiency Participation in daily exercise Cigarette smoking

Cigarette smoking 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. Daily exercise would be a measure to reduce a person's risk for vascular disease. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage to the blood vessels. Alcohol intake is unrelated to the development of chronic arterial insufficiency.

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

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

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

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? Ulnar artery Radial artery Brachial artery Femoral artery

Femoral

During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse? Brachial Femoral Temporal Popliteal

Femoral The femoral pulse is palpated in the groin (inguinal area) by compressing the femoral artery between skin and bone. The temporal pulse is located on the head. The brachial pulse is palpated medial to the biceps tendon in and above the bend in the elbow. The popliteal pulse is palpated behind the knee.

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

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.

When assessing a client for possible varicose veins, which of the following would the nurse do? Tell the client to raise his or her leg Obtain the ankle-brachial index Dorsiflex the client's foot Have the client stand for the exam

Have the client stand for the exam 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. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is used to assess the Homans' sign. The ankle-brachial index is used if the client has symptoms of arterial occlusion.

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

History of breast surgery Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Raynaud's disorder is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes and is typically bilateral. Peripheral artery disease involves reduced blood flow to the limbs and is characterized primarily by intermittent claudication, not by edema. Deep vein thrombosis is caused by obstruction of the veins and is not associated with lymphedema.

The nurse is planning care for a client recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development? Immobility Hypertension Smoking Obesity

Immobility Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis. Obesity is a risk factor for the development of arterial and venous disease. Smoking is a risk factor for arterial and venous disease and for the development of an abdominal aortic aneurysm. Hypertension is a risk factor for arterial disease and abdominal aortic aneurysm.

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply. Intraluminal valves Skeletal muscle contraction Cardiac output Activity level Respiration

Intraluminal valves Skeletal muscle contraction Respiration A pressure gradient created by respiration, skeletal muscle contraction, and intraluminal valves regulates blood flow in the venous system. It has not been shown that cardiac output or activity level affects this pressure gradient.

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication? Peripheral arterial disease Lymphedema Venous stasis Varicose veins

Lymphedema Lymphedema can be a result of scarring injury, removal of lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused by decreased arterial blood supply. Venous stasis is due to blood not moving which puts the client at risk for varicose veins.

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for Bruits over the radial artery. Lymphedema. Poor peripheral pulses. Raynaud disease.

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

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

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

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? Irregular-shaped ulcer on the inner aspect of the ankle Ulcer located on medial malleolus Pallor of foot occurs with elevation 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.

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? Neuropathy secondary to diabetes Venous disease Advanced chronic arterial occlusive disease Peripheral arterial disease

Peripheral arterial disease Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease.

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? Peripheral vascular problems Diabetes mellitus Obstruction in the femoral artery Calcium deficiency

Peripheral vascular problems The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.

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

Popliteal 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.

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

Posterior tibial The posterior tibial pulse is located in the groove between the medial malleolus and Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament. The popliteal pulse is located behind the knee lateral to the medial tendon. The dorsalis pedis pulse is located halfway up the foot, immediately lateral to the extensor tendon of the great toe.

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. 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. 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 client seeks medical attention for the condition shown. What finding does the nurse anticipate? Raynaud's disease Deep vein thrombosis Arterial insufficiency Venous insufficiency

Raynaud's disease Raynaud's disease is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness. The disorder commonly occurs bilaterally; symptoms last minutes to hours. Venous insufficiency, deep vein thrombosis, and arterial insufficiency all affect the blood vessels of the lower extremities.

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

Smoking Overweight Lack of exercise 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.

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

Thin, shiny, atrophic skin 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.

The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the client? Ankle-brachial index test Venous occlusion test Allen test Trendelenburg test

Trendelenburg test By the retrograde filling (Trendelenburg) test, you can assess the valvular competency in both the communicating veins and the saphenous system.

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? Upper arm Posterior neck Inguinal area Axillary area

Upper arm The epitrochlear nodes are located approximately 3 cm above the elbow on the inner aspect of the arm. The posterior cervical and occipital nodes would be palpated on the posterior aspect of the neck. The axillary lymph nodes would be palpated in the axillary area.

What should a nurse do if a posterior tibial pulse cannot be obtained on a client with edema of the feet? Use a Doppler to assess for the presence of the pulse. Assess for temperature only to determine circulation. Elevate the feet until the edema subsides. Document because some clients do not have this pulse.

Use a Doppler to assess for the presence of the pulse. Edema in the feet or ankles may make it difficult or impossible to palpate for the posterior tibial pulse. In these cases, a Doppler should be used to assess for adequate circulation. Elevating the feet will not enhance the pulse. Assessing temperature is not an alternative for assessing circulation because this client demonstrates edema, which shows that circulation is compromised. About 15% of healthy clients may not have a posterior tibial pulse present.

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem? Peripheral edema Coronary artery disease Raynaud's phenomenon Venous insufficiency

Venous insufficiency A rusty or brownish pigmentation around the ankles indicates venous insufficiency. This assessment finding is not suggestive of Raynaud's, CAD, or edema.

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

ankle. The posterior tibial pulse can be palpated behind the medial malleolus of the 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. Manifestations of arterial insufficiency include intermittent claudication to sharp, unrelenting, and constant. Diminished or absent pulses. Skin in cool to cold in temperature and there is a loss of hair over the toes and dorsum of the foot.

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

deep vein thrombosis Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphylococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues.

A student nurse learns that a pulmonary embolism may result from a DVT. The student knows to be alert for any signs of a pulmonary embolism including bradycardia pain in the legs diaphoresis bradypnea

diaphoresis Be alert for any signs of a PE, including acute dyspnea, chest pain, tachycardia, diaphoresis, and anxiety.

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 painless wound on the sole of the client's foot, which is surrounded by calloused skin A moderately painful wound on the lateral aspect of the client's ankle 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 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.

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's the difference?" Which statement would the nurse include in the response? "Arteries have thicker walls than veins." "Arteries carry 70% of the body's blood volume." "Arteries carry waste from the tissues." "Arteries have a lower pressure than veins."

"Arteries have thicker walls than veins." 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. Veins contain nearly 70% of the body's blood volume.

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? Venous insufficiency Diabetic neuropathy Arterial insufficiency Musculoskeletal weakness

Arterial insufficiency Cool, pale skin, delayed capillary refill, and absence of pulses are associated with arterial insufficiency. Pain, muscle cramping, and weakness with activity may indicate arterial disease. Musculoskeletal weakness would be associated with complaints of fatigue or a decrease in strength. With venous insufficiency, edema would most likely be noted. Neurologic impairment would include possible complaints of numbness, tingling, or changes in sensation.

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

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.

After a physical examination of the peripheral and vascular systems, the nurse determines that a client is at risk for the development of venous disease. What teaching would be appropriate for this client? (Select all that apply.) Avoid prolonged sitting and standing. Achieve a normal body weight. Limit alcohol intake. Participate in daily exercise. Drink an adequate amount of fluids.

Avoid prolonged sitting and standing. Achieve a normal body weight. Participate in daily exercise. Drink an adequate amount of fluids. For the client at risk for developing venous disease, the nurse should instruct the client to achieve a normal body weight, avoid dehydration, avoid prolonged sitting and standing, and participate in an exercise program. Limiting alcohol intake would be appropriate for the client at risk for developing arterial disease.

The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate? At the top of the foot Behind the ankle Just behind the knee In the groin area

Behind the ankle The posterior tibial pulse is palpated behind the medial malleolus of the ankle. The popliteal pulse is palpated just behind the knee. The dorsalis pedis pulse is palpated on the top of the foot along the great toe side. The femoral pulse is palpated in the groin area, just under the inguinal ligament.

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

Cool skin A cool extremity may be a sign of arterial insufficiency. The other findings listed are all normal.

The nurse is going to assess a client's ankle-brachial index. Which equipment will the nurse use for this assessment? (Select all that apply.) Doppler device Stethoscope Tape measure Reflex hammer Blood pressure cuff

Doppler device Blood pressure cuff To assess the ankle-brachial index, the nurse will apply a blood pressure cuff above the client's malleolus. The Doppler device is used to hear the blood flow as the blood pressure cuff is released. A tape measure, stethoscope, or reflex hammer is not used to assess the ankle-brachial index.

A finding on palpation that suggests venous insufficiency is: Ulcerations on toes of left foot Diminished dorsalis pedis pulse in an edematous foot Diminished sensations of dorsum of right foot Cool lower legs and feet

Diminished dorsalis pedis pulse in an edematous foot Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be on the sides of the foot and temperature is usually normal. Sensation does not tend to diminish.

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 Drinking large quantities of milk. Resting frequently. Getting regular exercise. Eating a high-protein diet.

Getting regular exercise. Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure, decreasing the risk for developing PVD.

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 except for: Hypertension Diminished sensation in pressure points Arterial insufficiency Venous insufficiency

Hypertension Hypertension is not directly associated with the formation of ulcers. It is an indirect risk factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to arterial insufficiency or neuropathy.

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? Intermittent claudication Shortness of breath Knee pain Chest pressure with exertion

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.

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 Cervical lymph nodes for tenderness and swelling Head and neck for recent ear infection or sore throat Abdomen, noting any organ enlargement or tenderness

Lower arm and hand for erythema and swelling 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. Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area.

A nurse is unable to palpate a client's radial and ulnar pulses. What is the most appropriate nursing action? Document the finding. Palpate the brachial pulse. Refer the client for medical follow-up. Auscultate the apical pulse.

Palpate the brachial pulse. 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. The nurse should not abandon this component of assessment. Referral is not always necessary, and further data are needed.

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound? There is a disruption in osmotic pressure in the client's extremities. Blood is returning from the client's toe more slowly than normal. There is a blockage or infection in the client's lymphatic system. The client's toe is receiving an inadequate supply of blood.

The client's toe is receiving an inadequate supply of blood. Arterial ulcers are frequently circular, painful, and deep. Venous ulcers, in contrast, are typically superficial with an irregular border. Disruptions in lymphatic function or osmosis would not result in a wound of this type.

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? Auscultate the anatomic area with a stethoscope. Use Doppler ultrasonography to locate the pulse. Ask another nurse to assess the pulse. Document absence of dorsalis pedis pulse.

Use Doppler ultrasonography to locate the pulse. 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. Asking another nurse to assess the pulse would be helpful in confirming the finding, especially if no pulse was obtained via Doppler. Auscultating with a stethoscope would not be helpful.

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? Dependent edema Arterial occlusion Venous insufficiency Stasis ulceration

Venous insufficiency Brown discoloration around the ankles occurs with chronic venous stasis resulting from hemosiderin deposits, which are byproducts of red blood cell degradation or iron deposits left behind from the process. There is no evidence of ulceration. Arterial occlusion would be associated with weak or absent pulses. Dependent edema is edema that results from the legs being in a dependent or down position. A brown pigmentation would not be present with dependent edema.

The nurse documents a 2+ radial pulse. What assessment data indicated this result? bounding pulse brisk, expected (normal) pulse diminished pulse absent (unable to palpate) pulse

brisk, expected (normal) pulse A +2 pulse is a normal pulse.

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 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.

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. What should the nurse do next? Reassess after applying warm compresses. Refer the client for medical follow-up. Document this finding as normal. Recheck in 5 minutes after elevating the arm.

Document this finding as normal. A capillary refill of less than 2 seconds is a normal finding and would be documented as such. The pulse would not need to be rechecked or reassessed. No referral would be necessary.

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? It drains capillary blood from the circulation. It produces protective antibodies. It filters harmful substances from the body. It manufactures T lymphocytes.

It filters harmful substances from the body. The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system.

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

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? Hypertrophic changes Venous insufficiency Arterial insufficiency Intermittent claudication

Venous insufficiency 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.

In assessing a client, a nurse palpates her epitrochlear lymph nodes and notes that the client may have an infection in the hand or forearm. The nurse understands that which of the following are functions of the lymphatic system? Select all that apply. Absorbs fats from the small intestine into the bloodstream Returns blood to the heart Drains excess fluid and plasma proteins from tissues and returns them to the venous system Delivers oxygen, water, and nutrients to the tissues Traps and destroys microorganisms and foreign materials filtered from lymph

Absorbs fats from the small intestine into the bloodstream. Drains excess fluid and plasma proteins from tissues and returns them to the venous system. Traps and destroys microorganisms and foreign materials filtered from lymph. The primary function of the lymphatic system is to drain excess fluid and plasma proteins from bodily tissues and return them to the venous system. These capillaries join to form larger vessels that pass through filters known as lymph nodes. The filtering, trapping, and destruction of microorganisms, foreign materials, dead blood cells, and abnormal cells by the lymph nodes allows the lymphatic system to perform a second function as a major part of the immune system defending the body against microorganisms. A third function of the lymphatic system is to absorb fats (lipids) from the small intestine into the bloodstream. The capillaries, not the lymphatic system, deliver oxygen, water, and nutrients to the tissues. Veins, not the lymphatic system, return blood to the heart.

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? Ask another nurse to assess the pulse. Listen for femoral bruits. Assess the popliteal pulse. Perform the Allen's test.

Listen for femoral bruits. Difficulty in palpating the femoral pulse could suggest arterial occlusion. Therefore the nurse should auscultate the femoral artery for bruits. Bruits over one or both femoral arteries suggest partial obstruction of the vessel and diminished blood flow to the lower extremity. Asking another nurse to assess the pulse may be appropriate but it would not provide as much information as auscultation would. If the femoral pulse is difficult to palpate, an occlusion may be present, making assessment of the popliteal pulse also difficult. The Allen test is done to evaluate the radial or ulnar arteries in the arm. The problem area here is the lower extremity.

A 72-year-old retired teacher comes to the clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes are risk factors for peripheral vascular disease? Coronary artery disease Osteoarthritis Migraine headaches Gastroesophageal reflux disease

Coronary artery disease Evidence of coronary artery disease implies that there is most likely disease in other vessels; therefore, this is a risk factor for peripheral vascular disease. Conversely, the presence of peripheral vascular disease is also a risk factor for coronary artery disease and, if present, should accompany reduction of cardiac risk factors.

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? Impaired Skin Integrity Imbalanced Nutrition Fear of Loss of Extremity Risk for Skin Breakdown

Impaired Skin Integrity This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented.

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? Deep vein thrombosis Varicose veins Intermittent claudication Pulmonary embolism

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, a anxiety. Deep vein thrombosis symptoms include pain, edema, and warmth of an extremity.

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? 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 Use a Doppler ultrasound device on the client's leg Have the client sit down

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.