Holistic Health EAQ: Perfusion Custom Quiz

What is the assessment of the carotid pulse?

Located along the medical edge of the sternocleidomastoid muscle neck , is an easily accessible site to assess physiologic shock or cardiac arrest

What is exophthalmos?

A symptom of Graves disease, which is characterized by overproduction of thyroid hormones the heart rate increases; the client is at risk for tachycardia, palpitations, and dysrhythmias.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovasular disease, diabetes, and vericose veins. To guide the assessment of the pain and cramping, the nurse would include question when completing the initial assessment? A. "Does walking for a long periods of time increase your pain?" B. "Does standing without moving decrease your pain?" C. "Have you had your potassium level checked recently?" D. "Have you had any broken bones in your lower extremities?"

A. "Does walking for a long periods of time increase your pain?"

When assessing a clients Vascular system, the nurse finds a Diminished and barely papable pulse strength. Which documentation would the nurse utilize in this situation? A. 1+ B. 2+ C. 3+ D. 4+

A. 1+

Which action would the nurse take FIRST after noting a flat line on a client's cardiac monitor? A. Assess the clients pulse B. Start cardiopulmonary resuscitation C. Check another lead to confirm asystole D. Call the hospital emergency response team

A. Assess the clients pulse Pulse should be immediately assessed because a lead or electrode coming off may cause a flat line on the monitor, mimicking asystole.

Which action would the nurse take for a client whose right radial pulse is weak and thready? Select all that apply. One, some, or all responses may be correct. A. Assessing all peripheral pulses B. Assessing and comaring radial pulses C. Asking a second nurse to assess the client's pulse D. Assessing for edema or other issues that may be restricting peripheral blood flow E. Observing for pallor/skin temperature differences distal to the weak pulse

A. Assessing all peripheral pulses B. Assessing and comaring radial pulses C. Asking a second nurse to assess the client's pulse D. Assessing for edema or other issues that may be restricting peripheral blood flow E. Observing for pallor/skin temperature differences distal to the weak pulse -If the client's radial pulse is weak and thready, further assessment would be indicated & includes assessing all peripheral pulses; assessing and comparing both radial pulses; asking another nurse to assess & verify the findings; assessing for any issues that may be restricting peripheral blood flow & observing color and temperature differences distal to the weak pulse

When taking the blood pressure of a client with hypertension, the nurse hears the first Korotoff sound at 125 mm Hg, then no sound is heard until the manometer reaches 100 mmHg, and then Korotkoff sounds are heard until sounds disappear completely at 72 mm Hg. Which findings would the nurse document? A. Auscultatory gap B. Pulsus paradoxus C. Widened pulse pressure D. Isolated systolic hypertension

A. Auscultatory gap -Pulsus Paradoxus or Paradoxial pulses: That the systole pressure is 10 mmHg or more higher during expiration than on inspiration. -Widened pulse: Is documented when the difference between the systolic and diastolic pressure is higher than 40 mm Hg. -Isolated systolic hypertension: Is when the systolic pressure is high but the diastolic number is normal

For which client would the nurse assess the carotid pulse? A. Client with cardiac arrest B. Client indicated for Allen test C. Client under physiological shock D. Client with impaired circulation to foot E. Client with impaired circulation to hand

A. Client with cardiac arrest C. Client under physiological shock -Ulnar Pulse: Allen Test -Posterior Tibial Pulse & Dorsalis Pedis Pulse: Circulation to the feet -Radial & Ulnar Pulse: Circulation to the hand

Which action would the nurse take to assess a client for a fungal infection of the toenails? A. Determining the rate of toenail growth B. Cutting the toenails straight across C. Observing the oral mucosa for cyanosis D. Checking capillary refill using fingernails

A. Determining the rate of toenail growth -B: Is an intervention suggested when the clients nail become tick or long, but that is not the assessment. -C: Nurse would assess for cyanosis using the oral mucosa in a client who has thick nails -D: Capillary refill: Assess by checking the client fingernails, but that does not indicate toenail infection.

Which findings would the nurse expect when assessing a client who has thrombophlebitis of the left lower leg? A. Edema of the left calf B. Weakness of the left foot C. Positive left sided babinski reflex D. Absence of left dorsalis pedis pulse

A. Edema of the left calf -Swelling of the extremity is indicative of thrombophlebitis because of the vein impairs venous return.

Which action would the nurse take NEXT when a client with a history of heart failure on daily weights has a 4-pound (1.8- kilogram) weight gain since the previous day? A. Perform a head to toe assessment B. Place the client on restricted fluid intake C. Discuss a restricted sodium diet with client D. Document the findings in the health care record.

A. Perform a head to toe assessment - Head to toe assessment, including vital signs would indicate symptoms, such as jugular distention with right sided heart failure, or pulmonary crackles associated with left sided heart failure. -B & C- More assessment is needed before restricting diets and fluid intake. D- Document findings is needed, but not as important as assessing the client.

While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit? A. Radial and apical pulse B. Apical and carotid pulse C. Radial and brachial pulse D. Apical and temporal pulse

A. Radial and apical pulse -Pulse deficit may be associated with an abnormal rhythm.Pulse deficit is the difference between the radial and apical pulse - Carotid pulse: measured when a clients condition worsens suddenly. -Brachial pulse: BP -Temporal pulse- Assess the pulse in children

The nursing student, under the supervision of the registered nurse (RN), plans to perform a pulse assessment. While preparing to assess the client, the RN ask the student to check the apical pulse after assessing the radial pulse. Which rationale supports the RN's request? A. The client my have dysrhythmia B. The client may have physiologic shock C. The client underwent surgery earlier in the day C. The client may have peripheral artery disease

A. The client my have a dysrhythmia -A client with dysrhythmia may have an intermittent or abnormal radial pulse. Apical pulse because it will be more accurate. -If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. -The femoral pulse is preferred to assess a client with peripheral artery disease.

Which pulse site would the nurse use to perform the Allen test? A. Ulnar B. Brachial C. Femoral D. Dorsalis pedis

A. Ulnar

Which clinical finding would the nurse expect to identify when assessing the lower extremities of a client with Varicose veins? A. Pallor B. Ankle edema C. Yellowed toenails D. Diminished pedal pulses

B. Ankle edema Ankle edema: Increased venous pressure -Pigmentation, not pallor, may occur with Varicosities -Yellow toenails occur with arterial, not venous, insufficiency. -Diminished pedal pulses occur with arterial, not venous, insufficiency

Which action would the nurse on the unit take FIRST when an older client with heart failure is transferred from the emergency department to the medical service? A. Interview the client for a health history B. Assess the client's heart and lung sounds. C. Monitor the client's peripheral pulse quality. D. Obtain the client's blood specimen for electrolytes.

B. Assess the client's heart and lung sounds. - First assessments would focus on detection of signs of severely decreased cardiac output, such as tachycardia & lung crackles, which would require rapid action to correct

Which assessment would the nurse complete after a client has an open reduction internal fixation of a fractured hip? A. Assess femoral pulse B. Assess toes for mobility C. Check condition of the pin D. Monitor range of motion of the knee

B. Assess toes for mobility -Monitoring the mobility of the toes assesses neural integrity distal to the surgical site; this is part of a neurovascular assessment.

Which assessment finding would the nurse expect to see in a client admitted to the hospital because of electric burns? SATA A. Coughing B. Burn order C. Smoky breath D. Leathery skin E. Cardiac arrest

B. Burn order D. Leathery skin E. Cardiac arrest -ELECTRICAL BURNS: have assessment findings such as burn order, leathery skin, and cardiac arrest due to hypovolemia & electrical disturbances. -Coughing & smoke breath are assessment findings associated with inhalational injuries

The nurse provides discharge instructions to a client for self-care after application of a cast to their fractured right ulna and radius. Which clinical manifestation would the nurse instruct the client to immediately report to their primary health care provider? A. Slight stiffness of the fingers B. Increasing pain at the injury site C. Small amounts of dark, blood drainage on the cast D. Bounding radial pulse in the affected extremity

B. Increasing pain at the injury site

Which findings by the nurse would be concerning after a client has had a permanent demand pacemaker implanted? A. Blood on the dressing B. Pulse rate 40 beats/ minute C. Blood pressure 104/76 mmHg D. Pain at the incisional site

B. Pulse rate 40 beats/ minute

Which action would the nurse take FIRST after obtaining a radial pulse rate or 136 beats/minute in a client with chronic atrial fibrillation? A. Ask about new stressors in the clients life B. Take the client's apical pulse for a full minute C. Notify the health care provider about the heart rate D. Ask where prescribed medication have been taken

B. Take the client's apical pulse for a full minute -Clients with atrial fibrillation frequently have a pulse deficit, so the nurse will first check an apical pulse over a full minute to determine the actual heart rate.

A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment would the nurse make?SATA A. Observe the client's ability to turn to the side-lying position B. Take the client's pedal pulse in the affected extremity C. Instruct the client to wiggle the toes of the right foot D. Ask the client if numbness of tingling is present in the right foot E. Instruct the client to attempt weight bearing on the right leg

B. Take the client's pedal pulse in the affected extremity C. Instruct the client to wiggle the toes of the right foot D. Ask the client if numbness of tingling is present in the right foot -Monitoring the pedal pulse will assess circulation to the foot.

Which area would the nurse palpate to assess a 4 year old childs radial pulse? A. Inner side of the ankle B. Thumb side of the forearm at the wrist C. Medial edge of the sternocleidomastoid muscle in the neck D. Fourth to fifth intercostal space at the left midclavicular line

B. Thumb side of the forearm at the wrist

Which assessment would the nurse perform to determine circulation to the feet of a 2 month old infant with recently applies casts for bilateral club foot (Talipes Equinovarus)? A. Alignment of legs on xray B. Warmth of the toes of both feet C. Mobility of the knees when flexed D. Presence of posterior tibial pulses

B. Warmth of the toes of both feet Peripheral vascular: assessment includes comparing temperature, color, sensation, mobility, capillary refill and if accessible, peripheral pulse

When assessing the brachial pulse what procedure is being done?

BP

Where is the posterior tibial site located? And what assessment?

Below the medical malleolus. It is used to assess the status of circulation in the foot.

Which characteristics of the pedal pulses would the nurse assess for when the client fractured hip? A. Contractility and rate B. Color of skin and rhythm C. Amplitude and symmetry D. Temperature and visible pulsations

C. Amplitude and symmetry -Assessment of the pedal pulse should include the strength of the pulse (Amplitude). Symmetry the correspondence of homologous parts on opposite side of the body, indicated whether the pulses are equal.

Which action would the nurse take NEXT after the nurse observes a client collapse while walking down the hallway, establishes unresponsiveness, and calls for help? A. Check for objects in the airway B. Begin chest compressions C. Check for a carotid pulse D. Deliver 2 deep breaths

C. Check for a carotid pulse According to the American heart associated guidelines (Canada: Heart and stroke foundation) Assessing for a carotid pulse is the first step in CPR. -Checking for objects blocking the airway would be done if ventilation is unsuccessful

When a client on the coronary care unit develops ventricular tachycardia, which action will the nurse take FIRST? A. Initiate immediate defibrillation B. Perform synchronized cardioversion C. Assess client's pulse and blood pressure D. Start cardiopulmonary resuscitation (CPR)

C. Assess client's pulse and blood pressure Ventricular tachycardia (VT) can be stable or unstable, the nurses first action will be to assess the client pulse and blood pressure.

Which action would the nurse PRIORITIZE after applying pressure to the nose of a client who is being treated for uncontrolled hypertension and develops a nosebleed? A. Add humidity to the clients oxygen B. Teach the client how to avoid nosebleeds C. Assess the clients blood pressure D. Obtain the clients pulse rate

C. Assess the clients blood pressure -Nosebleeds in adults may indicate hypertension.

Which prescribed action would the nurse take FIRST when a client who is admitted to the emergency department with a blood pressure of 240/150 mmHg reports severs headache, blurred vision, and swelling of the ankle? A. Obtain a glucose blood sample B. Collect urine and blood sample C. Assess the clients pulse and respirations D. Determine the amount of ankle edema

C. Assess the clients pulse and respirations

The nurse assess a clients pulse and documents the strength of the pulse 3+. Which pulse strength does this documentation refer to? A. Diminished B. Normal C. Full D. Bounding

C. Full -0: Absent pulse -1+: Diminished pulse. Barely palpable 2+: Normal pulse 4+bounding pulse

Which is the PRIORITY nursing intervention immediately after a client has a Ventricular demand pacemaker inserted? A. Encourage fluids B. Assess the implant site C. Monitor the heart rate and rhythm D. Encourage turning and deep breathing

C. Monitor the heart rate and rhythm - Assessment of the heart's rate and rhythm determines how the newly implanted pacemaker is functioning

Which findings would the nurse expect when assessing a client who has right ventricular failure? A. Slow pulse rate B. Pleural friction rub C. Neck vein distention D. Elevated temperature

C. Neck vein distention -Neck vein distention: Caused by Hypervolemia and pulmonary hypertension. The pulse is likely to be rapid and bounding

Which assessment finding for a 4 hours old newborn would be MOST concerning for the nurse? A. Acrocyanosis B. Irregular heartbear C. Paradoxical respiration D. Apical pulse in the 4th intercostal space

C. Paradoxical respiration -Paradoxial respiration: Exaggerated rise in the abdomen with respirations as the chest falls (Instead of the infant exhibiting abdominal respirations) This type of breathing is abnormal and should be reported -Acrocyanosis: Bluish discoloration of the hands. and feet, which is normal findings in the first 24 hours after birth -The apical pulse in a new born is located in the 4th intercostal space

What does the femoral artery pulse help assessing?

Circulation to the lower leg

What does the popliteal artery help assess?

Circulation to the lower leg

Which assessment would the nurse include in the plan of care for a postpartum client with large, painful varicose veins? A. Monitoring daily clotting times B. Assessing for peripheral pulses C. Monitoring daily hemoglobin values D. Assessing for signs of thrombophlebitis

D. Assessing for signs of thrombophlebitis Varicose veins predispose the client to Throbophlebitis; warmth, redness, and pain in the calf are sins of Thrombophlebitis.

Which finding for a client with acute coronary syndrome who is walking in the hallway will be important to communicate to the health care provider? A. Client has a premature atrial contraction while ambulating B. Client expresses anxiety about ambulating alone at home C. Pulse rate increases from 68 beats/minute to 80 beats/minute with ambulation D. Blood pressure drops from 130/72 mm Hg to 122/60 mmHg with ambulation

D. Blood pressure drops from 130/72 mm Hg to 122/60 mmHg with ambulation

To assess the status of circulation to the foot, which site would the nurse monitor for a pulse? SATA A. Carotid artery B. Femoral artery C. Popliteal artery D. Dorsalis pedis artery E. Posterior tibial artery

D. Dorsalis pedis artery E. Posterior tibial artery

Which position would the nurse place a client who presents to the emergency department with severe epistaxis? A. Trendelenburg position B. Semi-flower position on a stretcher C. Sitting in a chair with head tilted back D. Sitting with head tilted slightly forward

D. Sitting with head tilted slightly forward - Sitting position will reduce bleeding and allow for assessment of the quantity of bleeding.

When assessing a client for the dorsalis pedis pulse, the nurse documents the reading as 1+. Which conclusion can be inferred from this finding? A. There is absence of a pulse B. The pulse strength is normal C. The pulse strength is bounding D. The pulse strength is barely palpable

D. The pulse strength is barely palpable

Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? A. Count the pulse at another site B. Notify the primary health care provider C. Lower the legs to increase blood flow D. Verify the pulse by using a Doppler

D. Verify the pulse by using a Doppler Venous insufficiency often have edema. Which may make palpation of an arterial pulse difficult. A Doppler uses sounds waves so that the pulse can be heard. The nurse is assessing for pulse presence and quality, not pulse rate, when checkin pedal pulse

When assessing the Radial pulse what procedure is being done?

Heart rate

When assessing the ulnar pulse what procedure is being done?

Helps to evaluate the arterial insufficiency to the hand

Where is the carotid site located at? And what assessment?

The medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock of cardiac arrest when other sites are not palpable.

Where is the dorsalis pedis located at? And what assessment?

The top of the foot. This site is used to assess the status of circulation in the foot.

When assessing the Popliteal artery pulse what procedure is being done?

This is present behind the knee. This may be assess to evaluate popliteal aneurysms and peripheral vascular disease. Assessing the Circulation to the lower leg

Where is the ulnar located at? And what assessment?

Ulnar site of the forearm at the wrist. This is used to assess the status of circulation to the hand and to perform the Allen test.