CH 22 PrepU Peripheral Vascular Sys

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

A. Abdomen, noting any organ enlargement or tenderness (pg 468-479)

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

A. DVT

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 vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system? a. Intermittent claudication b. Knee pain c. Chest pressure with exertion d. Shortness of breath

A. Intermittent claudication (pg 468)

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

A. Nontender, mobile, and 1 cm in diameter (pg 479)

A client seeks medical attention for the condition shown (hands using color). What finding does the nurse anticipate? A. Raynaud's disease B. Venous insufficiency C. Deep vein thrombosis D. Arterial insufficiency

A. Raynaud's Disease

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? A. Venous thromboembolism B. Fluid imbalance C. Sepsis D. Decreased mobility

A. Venous thromboembolism

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

A. brachial pulse

The nurse is unable to palpate a client's left popliteal artery. Which artery should be assessed to determine the presence of blood flow in the left leg? a. femoral b. saphenous c. dorsalis pedis d. posterior tibial

A. femoral (weber, pg 465)

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 A. venous insufficiency. B. ankle edema. C. arterial occlusive disease D. venous ulcers.

A. venous insufficiency

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

A. venous insufficiency (pg. 478)

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? a. Deep vein thrombosis b. Arterial occlusion c. Pulmonary embolism d. Venous thromboembolism

B.

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

B. (weber, pg 475)

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

B. 1.00 (pg 486)

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 be added to the plan of care? A. Risk for peripheral neurovascular dysfunction B. Altered tissue perfusion, arterial related to reduced blood flow C. Pain related to decreased blood flow and altered tissue perfusion D. Activity intolerance related to pain and claudication with ambulation

B. Altered tissue perfusion, arterial related to reduced blood flow

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? (color change) A. Intermittent claudication B. Arterial insufficiency C. Femoral pulse D. Lymphedema

B. Arterial insufficiency (pg 482)

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? a. Palpate the right leg with the client in supine position. b. Assist the client to the prone position and palpate again. c. Place the client in the lateral position and palpate. d. Elevate and palpate the left leg in supine position.

B. Assist the client to the prone position and palpate again (pg 480)

A client with peripheral vascular disease is discharged from the health care facility. Which risk-reduction teaching tip should the nurse discuss during discharge teaching? A. Decrease dietary fiber intake. B. Avoid smoking. C. Eat a low-protein diet. D. Limit physical activity.

B. Avoid smoking

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

B. Check the insertion site for redness

A patient has developed an infection of the right forearm. The nurse will focus the assessment of the patient's lymphatic system on which area? A. Lateral axillary B. Epitrochlear C. Central axillary D. Infraclavicular

B. Epitrochlear

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

B. History of breast surgery (pg 474)

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. Legs should be elevated for 15 seconds C. Have the client stand upright after tourniquet removal D. Tourniquet should be put on before leg elevation

B. Legs should be elevated for 15 seconds

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? A. Advanced chronic arterial occlusive disease B. Peripheral arterial disease C. Venous disease D. Neuropathy secondary to diabetes

B. Peripheral arterial disease

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate? A. Atherosclerosis B. Normal finding C. No lymphedema D. Possible lymphoma

B. normal finding

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

D. Cool foot temperature and ulceration on the client's great toe

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

C, D

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

C. "The area of cramping is close to the area of arterial occlusion." (468)

What is a long-term complication of peripheral vascular disease? A. Metabolic changes B. Diabetes mellitus C. Amputation D. Thickened skin

C. 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? a. CT scan of the lower legs b. PET scan c. Ankle-brachial index (ABI) d. Venogram

C. Ankle-brachial index (ABI) (pg 471)

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? A. Obtain an order for ankle brachial index test to be performed. B. Check the extremity for findings of decreased blood flow. C. Assess adequacy of blood flow using a Doppler device. D. Attempt to palpate the posterior tibial pulse.

C. Assess adequacy of blood flow using a Doppler device (pg 471)

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. A. Previous use of hormones B. Stress-reduction techniques C. Cigarette smoking D. Regular exercise E. High-fat diet F. Low alcohol intake

C. Cigarette smoking A. Previous use of hormones E. High-fat diet (pg 471)

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? A. Varicose veins B. Pulmonary embolism C. Intermittent claudication D. Deep vein thrombosis

C. Intermittent claudication (pg 468)

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

C. Lower arm and hand for erythema and swelling (pg. 468)

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

C. Palpate both radial arteries for symmetry (pg 464)

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

C. Quitting smoking and keeping good control of your blood sugar levels are important.

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves? a. Allen test b. Position change test c. Trendelenburg test d. Ankle-brachial pressure index (ABPI)

C. Trendelenburg test (pg. 474)

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward? A.Ulnar B. Epitrochlear C. Brachial D. Radial

C. brachial (pg 476)

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 A. resting frequently. B. drinking large quantities of milk. C. getting regular exercise. D. eating a high-protein diet.

C. 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 A. Raynaud disease. B. bruits over the radial artery. C. lymphedema. D. poor peripheral pulses.

C. lymphedema

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? A. superficial popliteal node B. superficial inguinal node C. right cervical node D. lumbar node

C. right cervical node

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

D. Cool skin

The nurse assesses the client as shown. What pulse is the nurse assessing? (picture of ankle w/ hand on inner side) A. Femoral B. Popliteal C. Dorsalis pedis D. Posterior tibial

D.

Which statement made by a student nurse concerning how to test a client for a paradoxical pulse would indicate that the nurse needs further education? a. "Inflate the blood pressure cuff to a pressure higher than the client's usual systolic pressure." b. "Note the pressure level at the point where the first sounds can be heard." c. "Drop the pressure until that point where sounds can be heard throughout the respiratory cycle." "d. The difference between the pressures at the two levels is normally no greater than 5 mm Hg."

D.

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

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

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

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

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

D. Cold fingers and hands

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

D. Firmly compress the lower portion of the varicose vein

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? A. Fear of Loss of Extremity B. Imbalanced Nutrition C. Risk for Skin Breakdown D. Impaired Skin Integrity

D. Impaired Skin Integrity

The popliteal artery can be palpated at the A. inguinal ligament. B. great toe. C. ankle. D. knee.

D. Knee

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

D. Notify the healthcare provider

Which area of the arm drains to the epitrochlear nodes? A. Ulnar surface of the forearm and hand; second, third, and fourth fingers B. Radial surface of the forearm and hand, thumb and index finger, and radial middle finger C. Radial surface of the forearm and hand; second, third, and fourth fingers D. Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger

D. Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger (pg 468-476)

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

False

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

True

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? a. Hypertrophic changes b. Arterial insufficiency c. Venous insufficiency d. Intermittent claudication

c. Venous insufficiency (pg. 488)