Jarvis: Chapter 20 Peripheral Vascular System and Lymphatic System
The nursing instructor is talking with a nursing student about the superficial nodes of the lymphatic system that are accessible to inspection and palpation. Which statement by the nursing student indicates effective learning? "Cervical nodes drain the head and neck." "Axillary nodes drain the hand and lower arm." "Epitrochlear nodes drain the breast and upper arm." "Inguinal nodes drain the posterior abdominal wall."
"Cervical nodes drain the head and neck." Rationale Cervical nodes are present in the neck, and they help to drain the lymph from the head and the neck. Axillary nodes are present in the axillary region and drain the breast and the upper arm. Epitrochlear nodes are present in the antecubital fossa and drain the hand and the lower arm. The inguinal nodes in the groin drain most of the lymph of the lower extremities, the external genitalia, and the anterior abdominal wall. p. 513
The instructor is verbally quizzing a nursing student about the difference between the arterial and venous systems. Which statement by the nursing student is an accurate response? "The walls of the arteries are thinner, and the walls of the veins are thicker." "The arteries are high-pressure systems, and the veins are low-pressure systems." "The arteries contain intraluminal valves, and the veins are devoid of intraluminal valves." "The arteries build up metabolic wastes, and the veins cause symptoms of oxygen deficit."
"The arteries are high-pressure systems, and the veins are low-pressure systems." Rationale Arteries carry oxygenated blood pumped by the heart to all the tissues. The blood pressure inside the arteries is greater than that in the veins. Therefore, arteries are the high-pressure systems. Veins do not have any mechanism to pump the blood; therefore, veins are low-pressure systems. The walls of the veins are thinner and the walls of the arteries are thicker. The veins contain intraluminal valves to maintain unidirectional blood flow. The arteries are devoid of these intraluminal valves. The diseases associated with veins build up metabolic wastes in the body. The diseases associated with arteries produce signs and symptoms of oxygen deficit. pp. 509-511
The nurse is teaching a nursing student about the functions of the spleen. Which statement by the student nurse is a misunderstanding that needs correction? <p>The nurse is teaching a nursing student about the functions of the spleen. Which statement by the student nurse is a misunderstanding that needs correction?</p> "The spleen produces antibodies." "The spleen stores old red blood cells." "The spleen destroys old red blood cells." "The spleen filters microorganisms from the blood."
"The spleen stores old red blood cells." Rationale The spleen does not store old red blood cells, but it does destroy old red blood cells at the end of their life span. In addition, the spleen produces antibodies and filters microorganisms from the blood. p. 513
The nurse is assessing the probability of deep vein thrombosis (DVT) in a patient. While performing the pretest, the nurse documents the clinical characteristics as swelling of the entire leg, collateral superficial non-varicose veins, localized tenderness along the distribution of the deep venous system, and an alternative diagnosis at least as likely as DVT. What is the total score of DVT probability in this patient? Record your answer using a whole number.
1 Rationale The clinical characteristics documented during the pretest are swelling of the entire leg = 1; collateral superficial non-varicose veins = 1; localized tenderness along the deep venous distribution = 1; alternate diagnosis at least as likely as DVT = -2. Therefore, the total score of DVT probability in the patient will be 1 + 1 + 1 - 2 = 1. p. 526
The nurse records the patient's blood pressure at 85/60 mm Hg for inspiration and 110/60 mm Hg for expiration. Which conditions are likely to be associated with this finding? Acute asthma Cardiomyopathy Cardiac tamponade Chronic hypertension Aortic valve stenosis
Acute asthma Cardiac tamponade Rationale Pulsus paradoxus is associated with a decrease in blood pressure by more than 10 mm Hg during inspiration. In this condition, the systolic blood pressure is 15 mm Hg lower during inspiration than during expiration. Therefore, the blood pressure findings of 85/60 mm Hg for inspiration and 110/60 mm Hg for expiration indicate pulsus paradoxus. Cardiac tamponade is associated with accumulation of fluid around the heart, which prevents complete expansion of the ventricles. This leads to a decrease in blood pressure during inspiration. Acute asthma is associated with bronchoconstriction, which results in breathing difficulty and a decrease in blood pressure during inspiration. Cardiomyopathy and chronic hypertension are associated with increased blood pressure and reduced blood flow, resulting in pulsus alternans. Aortic valve stenosis is associated with reduced blood supply and a decrease in blood pressure, resulting in a weak, thready pulse. p. 530
A bedridden patient with hypertension reports sudden sharp pain in the legs. The nurse finds the patient's legs to be warm, red, and edematous. Which class of medications would be most beneficial for the patient? Analgesics Antibiotics Anticoagulants Antihypertensives
Anticoagulants Rationale Patients who are on prolonged bed rest may have reduced blood flow due to restricted mobility. This results in the formation of clots in the veins, sudden sharp muscle pain, warmness, redness, and swelling in the legs, indicating venous thromboembolism. Therefore, anticoagulant medications would be the most beneficial to alleviate the patient's symptoms, because they reduce clot formation and increase blood flow. Analgesic medications provide pain relief, but they do not prevent clot formation. Antibiotics destroy microbes and alleviate the symptoms of infection but do not help in venous thromboembolism. Antihypertensives reduce blood pressure but not venous thromboembolism. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. p. 514
The nurse is caring for an obese patient with atherosclerosis. According to the laboratory reports, the patient has high serum cholesterol levels. Which other complication does the nurse expect in the patient? Aortic aneurysm Deep venous thrombosis Aortoiliac occlusion Varicose veins
Aortic aneurysm Rationale An aortic aneurysm is a sac formed by the dilation of the arterial wall. This condition occurs commonly in patients with atherosclerosis. This condition occurs because of the overenlargement of the inner and outer layers of the aorta. Deep venous thrombosis occurs because of the formation of clots in the veins of the lower extremities. This condition is not associated with atherosclerosis. Aortoiliac occlusion results in erectile dysfunction, and it occurs because of the occlusion of the artery. Atherosclerosis is not a risk factor for this condition. Varicose veins are common in obese adults, but they do not result from atherosclerosis. p. 535
The nurse is caring for an obese patient with atherosclerosis. According to the laboratory reports, the patient has high serum cholesterol levels. Which other complication does the nurse expect in the patient? Aortic aneurysm Deep venous thrombosis Aortoiliac occlusion Varicose veins
Aortic aneurysm Rationale An aortic aneurysm is a sac formed by the dilation of the arterial wall. This condition occurs commonly in patients with atherosclerosis. This condition occurs because of the overenlargement of the inner and outer layers of the aorta. Deep venous thrombosis occurs because of the formation of clots in the veins of the lower extremities. This condition is not associated with atherosclerosis. Aortoiliac occlusion results in erectile dysfunction, and it occurs because of the occlusion of the artery. Atherosclerosis is not a risk factor for this condition. Varicose veins are common in obese adults, but they do not result from atherosclerosis. p. 535
What advice should the nurse provide to a diabetic patient to prevent foot problems? Avoid adding oils to bathwater. Avoid leaving chipped nail polish on. Avoid covering discolored nails with nail polish. Avoid writing the alphabet A to Z with the foot. Avoid drying the feet after a shower to maintain moisture.
Avoid leaving chipped nail polish on. Avoid covering discolored nails with nail polish. Rationale The nurse advises the patient to avoid chipped nail polish because it supports the growth of a large number of microorganisms on the nails. The nurse also advises the patient to avoid covering discolored nails with nail polish because it locks the moisture in and enhances bacterial growth. The patient need not avoid adding oils to bathwater, but he or she should be careful when doing so, because they can make the bath tub slippery. The nurse advises the patient to try writing the alphabet from A to Z with the foot to promote blood flow. The nurse advises the patient to dry the feet carefully after a shower or bath for proper foot hygiene. p. 527
The nurse finds that a patient has risk of atherosclerosis. What advice would the nurse provide to the patient to prevent further complications? <p>The nurse finds that a patient has risk of atherosclerosis. What advice would the nurse provide to the patient to prevent further complications? </p> Increase the fluid intake. Avoid smoking cigarettes. Avoid a sedentary lifestyle. Use compression garments. Reduce the intake of fatty foods.
Avoid smoking cigarettes. Avoid a sedentary lifestyle. Reduce the intake of fatty foods. Rationale Atherosclerosis is the deposition of cholesterol in the walls of the arteries, resulting in decreased blood flow. Cigarette smoking impairs the metabolism of triglycerides, resulting in the accumulation of cholesterol in the arteries. Therefore, the nurse should advise the patient to avoid smoking. A decrease in physical activity can cause accumulation of excess fat in the body that can result in atherosclerosis. An increase in serum cholesterol causes deposition of fatty streaks in the blood vessels, resulting in atherosclerosis. Therefore, the nurse should advise the patient to reduce the intake of fatty foods. Increased fluid intake helps to prevent dehydration, but it does not reduce serum cholesterol levels. Compression garments help to alleviate the symptoms caused by distended arteries; however, they do not reduce the cholesterol levels in the body. p. 535
The nurse finds that a patient has risk of atherosclerosis. What advice would the nurse provide to the patient to prevent further complications? Increase the fluid intake. Avoid smoking cigarettes. Avoid a sedentary lifestyle. Use compression garments. Reduce the intake of fatty foods.
Avoid smoking cigarettes. Avoid a sedentary lifestyle. Reduce the intake of fatty foods. Rationale Atherosclerosis is the deposition of cholesterol in the walls of the arteries, resulting in decreased blood flow. Cigarette smoking impairs the metabolism of triglycerides, resulting in the accumulation of cholesterol in the arteries. Therefore, the nurse should advise the patient to avoid smoking. A decrease in physical activity can cause accumulation of excess fat in the body that can result in atherosclerosis. An increase in serum cholesterol causes deposition of fatty streaks in the blood vessels, resulting in atherosclerosis. Therefore, the nurse should advise the patient to reduce the intake of fatty foods. Increased fluid intake helps to prevent dehydration, but it does not reduce serum cholesterol levels. Compression garments help to alleviate the symptoms caused by distended arteries; however, they do not reduce the cholesterol levels in the body. p. 535
The nurse is assessing an elderly patient for the presence of peripheral vascular complications. Which nursing actions are appropriate during a peripheral vascular examination? Assessing the weight of the patient Checking the epitrochlear nodes of the patient Palpating the femoral pulse of the patient Palpating the inguinal nodes of the patient Assessing the body temperature of the patient
Checking the epitrochlear nodes of the patient Palpating the femoral pulse of the patient Palpating the inguinal nodes of the patient Rationale Peripheral vascular examination involves the palpation of lymph nodes, palpation of the pulse, and evaluation of the skin changes of the extremities. The nurse palpates the epitrochlear nodes to check for enlargement, which would indicate infection. Palpation of the femoral pulse helps the nurse to identify the type of pulse in the patient. The pulse is an index for various peripheral vascular complications. Palpation of the inguinal nodes helps the nurse to assess the presence of infections that may lead to vascular complications in the patient. Assessing the patient's body weight is not a part of the peripheral vascular examination, because it does not give any clue about the presence of complications. Peripheral vascular examination includes palpating for the temperature of the hands and feet, but not body temperature. The temperature of the hands and feet may increase or decrease because of peripheral vascular complications. p. 518
The nurse is assessing a patient who uses oral contraceptives and is at risk for deep vein thrombosis. Which medication would be helpful to ensure the patient's safety? <p>The nurse is assessing a patient who uses oral contraceptives and is at risk for deep vein thrombosis. Which medication would be helpful to ensure the patient’s safety?</p> Ibuprofen (Advil) Clopidogrel (Plavix) Acetaminophen (Tylenol) Estradiol (Estrace)
Clopidogrel (Plavix) Rationale Deep vein thrombosis involves the formation of blood clots inside the veins of the lower extremities. Oral contraceptives may also cause the formation of blood clots in the peripheral blood vessels. Clopidogrel (Plavix) is an anticoagulant that prevents the activation of blood platelets and thereby prevents the formation of blood clots. Analgesic medications such as ibuprofen (Advil) and acetaminophen (Tylenol) help to alleviate the pain associated with arterial or venous insufficiency. Estradiol (Estrace) increases the activity of oral contraceptives. Therefore, this medication increases the risk of thrombosis in the patient. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 514
The nurse is preparing a patient to determine ankle-brachial index (ABI). The nurse finds that the patient has smoked 5 minutes before coming for the test. What is the most important nursing intervention in this situation? Conducting the test 2 hours later Instructing the patient to lie in the supine position for 20 minutes Using the Doppler probe to determine the patient's blood pressure Placing the ankle cuff just above the malleoli with straight wrapping
Conducting the test 2 hours later Rationale Cigarettes contain nicotine, a central nervous stimulant that may increase blood pressure and lead to false ABI results. Therefore, the nurse should avoid conducting the test for 2 hours after the patient has smoked. The nurse should ask the patient to rest in the supine position for 5 to 10 minutes before the test, because this helps to stabilize the patient's blood pressure, but lying in this position for a full 20 minutes may decrease blood pressure and affect the test results. The Doppler probe can be used to determine the brachial and ankle measurements, but it is most important to wait 2 hours before determining the ABI. Placing the ankle cuff just above the malleoli helps to determine the ABI accurately, but performing this intervention immediately after smoking will not be helpful. pp. 525
The nurse is teaching a patient with diabetes about foot care. Which instructions should the nurse include about maintaining blood flow to the feet? Curl and spread out the toes frequently. Dry feet carefully after a shower or bath. Apply a thin coat of lotion on the skin. Take a warm footbath occasionally. Keep the toenails trimmed and straight.
Curl and spread out the toes frequently. Take a warm footbath occasionally. Rationale The nurse should teach proper methods of maintaining clean, healthy feet to prevent complications in diabetic patients. Curling and spreading of the toes frequently helps to maintain proper blood flow to the feet. Occasional warm baths also stimulate the blood flow to the feet and help to avoid vascular complications in the lower extremities. Drying the feet carefully after a shower or bath helps to prevent infections, but it does not help to maintain blood flow. Applying a thin coat of lotion on the skin of the feet helps to maintain moisture, but this intervention does not help to maintain blood flow. The nurse instructs the patient to keep the toenails trimmed and straight to prevent infections. This intervention does not help to stimulate blood flow to the feet. p. 527
While assessing a patient with venous insufficiency, the nurse finds that the patient has edema in the lower extremities. The nurse also finds that the skin of the lower extremities is thick and has brownish discoloration. What could be the reason for such findings in the patient? Occlusion of a deep vein Degradation of red blood cells Bacterial invasion of the tissues Degradation of white blood cells
Degradation of red blood cells Rationale The patient may have edema in the lower extremities and the sensation of fullness in the legs because of venous insufficiency. Deposition of hemosiderin, which is a product of red blood cell degradation, may occur in the patient with venous insufficiency. This leads to the brownish discoloration and thickening of the skin. The occlusion of a deep vein causes unilateral edema in either upper or lower extremities. It is not associated with brownish discoloration of the skin. Bacterial invasion of poorly drained tissues may cause venous ulcers. The patient may have swelling and enlarged lymph nodes when there is an infection due to degradation of white blood cells. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 533
While assessing a patient with chronic venous insufficiency, the nurse finds dilated, bulged, and tortuous veins. The patient also reports severe leg cramps. Which technique helps infurther assessing the patient's medical condition? Profile sign Capillary refill Modified Allen test Doppler ultrasound
Doppler ultrasound Rationale In the patient with chronic venous insufficiency, the superficial veins, including the small and great saphenous veins, are affected. Bulged and tortuous veins along with leg cramping indicate the presence of varicose veins. Further assessment is necessary to assess the valve incompetency in the varicose veins. Imaging with Doppler ultrasound is an objective, noninvasive, reliable measure of valvular incompetency. The patient with congenital cyanotic heart disease may not have dilated and tortuous veins in the legs. The nurse uses the profile sign technique to evaluate clubbing in the patient with congenital cyanotic heart disease. The capillary refill technique is an indicator of peripheral perfusion and cardiac output. It indicates the time taken for return of skin color when the vessels are depressed or blanched. The modified Allen test helps to evaluate the adequacy of collateral circulation before cannulating the radial artery. p. 523
Which veins conduct most of the venous return from the legs? <p>Which veins conduct most of the venous return from the legs? </p> Femoral veins Popliteal veins Perforator veins Small saphenous veins Great saphenous veins
Femoral veins Popliteal veins Rationale The femoral and popliteal veins are the deep veins that run in the legs and are responsible for conducting most of the venous return. A perforator vein is a connecting vein that joins a superficial vein and a deep vein. It does not conduct most of the venous return from the legs. The small saphenous veins and the great saphenous veins are the superficial veins that supply blood to the deep veins, but they do not conduct most of the venous return from the legs. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 510
For which complications should the nurse monitor in a patient with deep vein thrombosis? Hypotension Heart failure Diabetes mellitus Hyperthyroidism Myocardial infarction
Heart failure Myocardial infarction Rationale Deep vein thrombosis is associated with the formation of a blood clot in the veins, resulting in reduced blood supply to the tissues. A decrease in blood supply to the tissues causes tissue death, resulting in heart failure and myocardial infarction. The clot present in the veins obstructs the flow of blood and increases the blood pressure. Therefore, the patient with deep vein thrombosis may have hypertension, not hypotension. Diabetes mellitus is associated with an increase in blood glucose levels. Deep vein thrombosis is unrelated to diabetes mellitus. Hyperthyroidism is caused by an increase in thyroxine hormone levels, not by deep vein thrombosis. p. 534
The nurse is caring for a patient who has lymphatic obstruction. Which complication does the nurse monitor for in the patient? <p>The nurse is caring for a patient who has lymphatic obstruction. Which complication does the nurse monitor for in the patient? </p> Peptic ulcer Hypotension Heart failure Hepatic cirrhosis Nephrosis
Heart failure Hepatic cirrhosis Nephrosis Rationale Lymphatic obstruction causes accumulation of fluid in the tissues, resulting in bilateral pitting edema and cardiovascular disorders. Therefore, the patient with lymphatic obstruction may have heart failure due to the increase in the blood volume. Reduced clearance of the intestinal fluid may impair hepatic and renal functioning and cause hepatic cirrhosis and nephrosis. Lymphatic obstruction will not increase the secretion of gastric acid and will not cause peptic ulcer. Because of the accumulation of fluid, lymphatic obstruction may lead to hypertension but not hypotension. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 523
A patient who is in the third trimester of pregnancy has increased venous pressure and reduced blood flow because of obstruction of the iliac veins and inferior vena cava. Which complications may the patient develop related to these findings? <p>A patient who is in the third trimester of pregnancy has increased venous pressure and reduced blood flow because of obstruction of the iliac veins and inferior vena cava. Which complications may the patient develop related to these findings? </p> Hemorrhoids Pulmonary embolism Varicosities in the vulva Varicosities in the legs Increased uterine contractions
Hemorrhoids Varicosities in the vulva Varicosities in the legs Rationale The growing fetus blocks the iliac veins and inferior vena cava during pregnancy. This reduces the drainage of fluid from the iliac veins and inferior vena cava, resulting in increased venous pressure and reduced blood flow. Because of the accumulation of blood and fluid in the veins, pressure builds up in the veins and may cause hemorrhoids, varicosities in the vulva, and varicosities in the legs. Obstruction of the pulmonary veins results in pulmonary embolism. Therefore, obstruction of the iliac veins and inferior vena cava will not cause a pulmonary embolism. Obstruction of the iliac veins and inferior vena cava will not increase the contractility of the uterine muscles. Therefore, the patient will not have increased uterine contractions. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 514
The nurse is caring for a patient with atherosclerosis. Which intervention should the nurse follow to obtain this patient's ankle-brachial index? Place the patient in the sitting position. Instruct the patient to be in a standing position. Maintain the room temperature at 22 o C (72 o F). Provide fluids to the patient before the examination.
Maintain the room temperature at 22 degrees C (72 degrees F). Rationale The room temperature may cause vasodilation and vasoconstriction resulting in the variation of the blood pressure. Therefore, in order to determine the patient's blood pressure accurately, the nurse should maintain the room temperature at 22 o C (72 o F). The patient should be in a supine position to measure ankle and arm blood pressures; the patient should not be sitting or standing. Providing fluids to the patient increases the fluid content and may increase the blood pressure. Therefore, providing fluids before the examination may alter the blood pressure. p. 516
Which conditions are associated with venous pooling? Obesity Smoking Diabetes Arteriosclerosis Multiple pregnancies
Obesity Multiple pregnancies Rationale Venous pooling is the accumulation of blood in the veins of the legs because of gravitational pull when a patient changes position. Obesity and multiple pregnancies are the risk factors for venous pooling. Smoking is a risk factor for vascular diseases, but it does not cause venous pooling of the blood. Venous stasis is a condition of slow blood flow in the veins, usually of the legs. Venous stasis is a risk factor for forming blood clots in the veins of diabetic patients. Arteriosclerosis is associated with arterial insufficiency but not venous insufficiency. p. 512
Which pathologic condition leads to the accumulation of lymph in the breasts and upper arms? Obstruction of the cervical nodes Obstruction of the axillary nodes Obstruction of the inguinal nodes Obstruction of the epitrochlear nodes
Obstruction of the axillary nodes Rationale The lymph from the breasts and the upper arms drains into the axillary nodes. Obstruction of the axillary nodes results in the accumulation of lymph in the breasts and the upper arms. Obstruction of the cervical nodes results in the accumulation of lymph in the head and the neck, because they drain the lymph from the head. Obstruction of the inguinal nodes results in the accumulation of lymph in the genitalia and the abdomen. This is because they drain the lymph from the external genitalia and the anterior abdominal wall. Obstruction of the epitrochlear nodes results in the accumulation of lymph in the hands and lower arms, because these nodes drain the lymph from the hands and the lower arms. p. 513
While assessing the radial pulse of the patient, the nurse finds that the strength of the pulse increases rapidly and collapses subsequently. Which conditions may be responsible for this finding in the patient? <p>While assessing the radial pulse of the patient, the nurse finds that the strength of the pulse increases rapidly and collapses subsequently. Which conditions may be responsible for this finding in the patient? </p> Hyperthyroidism Aortic valve stenosis Patent ductus arteriosus Aortic valve regurgitation Premature ventricular contraction
Patent ductus arteriosus Aortic valve regurgitation Rationale A pulse that increases rapidly and collapses subsequently is known as a water-hammer (Corrigan) pulse. The water-hammer (Corrigan) pulse is associated with an increase in stroke volume and a decrease in peripheral resistance. This type of pulse is manifested in conditions such as patent ductus arteriosus and aortic valve regurgitation. Hyperthyroidism, aortic valve stenosis, and premature ventricular contraction are not associated with the water-hammer (Corrigan) pulse. Hyperthyroidism is associated with high blood pressure that results in a full and bounding pulse, which is easily palpable. Aortic valve stenosis is associated with pulsus bisferiens, in which each pulse is associated with two strong systolic peaks with a dip between them. Premature ventricular contraction is associated with pulsus bigeminus, which is associated with a normal heartbeat followed by a premature heartbeat. p. 530
A patient who is in the third trimester of pregnancy has generalized edema and a blood pressure of 140/90 mm Hg. Which complication should the nurse look for in the patient? Preeclampsia Lymphadenopathy Gestational diabetes Deep venous thrombosis
Preeclampsia Rationale Hypertension and generalized edema in a pregnant patient may indicate preeclampsia. Increased blood pressure due to edema and placental dysfunction are the causes of preeclampsia. Swollen or enlarged lymph nodes indicate lymphadenopathy and may occur in a patient who has an infection. They are not associated with edema and hypertension during pregnancy. The hormonal changes occurring during pregnancy cause impaired glucose tolerance, which may result in gestational diabetes. Hypertension is not a risk factor for gestational diabetes. Deep venous thrombosis may occur in the patient who gave birth by means of a cesarean section. Generalized edema and hypertension do not indicate deep venous thrombosis. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 526
While assessing a patient with congenital cyanotic heart disease, the nurse finds that the patient has a flattened nail bed angle and diffuse enlargement of the terminal phalanges. Which technique does the nurse use for the assessment? Profile sign Capillary refill Modified Allen test Doppler ultrasound probe
Profile sign Rationale The patient with congenital cyanotic heart disease may have flattening of the nail bed angle and clubbing of the fingers. The nurse uses the profile sign technique to assess these signs. The profile sign technique involves viewing the fingers from the sides. It helps in the detection of early clubbing of the fingers. The capillary refill technique is used as an index to determine peripheral perfusion and cardiac output. The modified Allen test helps to evaluate the adequacy of collateral circulation before cannulating the radial artery. A Doppler ultrasound probe helps to detect a weak peripheral pulse, monitor blood pressure in infants or children, and measure blood pressure in the lower extremities. The Doppler ultrasound probe magnifies the pulsatile sounds of the heart and blood vessels. p. 516
The nurse observes bilateral pitting edema and abnormal distention of the jugular veins in a patient. Which condition is the patient likely to have? Hyperthyroidism Diabetes mellitus Cervical malignancy Pulmonary hypertension
Pulmonary hypertension Rationale The jugular veins are located in the neck. The presence of bilateral pitting edema and abnormal distention of the neck veins indicate that the patient has pulmonary hypertension. These signs are due to the pressure exerted by the blood on the veins. Hyperthyroidism is associated with an increase in thyroxine levels. It may result in a full and bounding pulse but not abnormal distention of the veins. Diabetes mellitus is associated with an increase in blood glucose levels and may cause atherosclerosis. It does not manifest as bilateral pitting edema and abnormal distention of veins in the neck. Cervical malignancy may cause an increase in blood pressure, but it does not cause abnormal distention of neck veins. p. 523
The nurse is assessing a patient with aortic valve stenosis. The nurse checks the pulse over the carotid artery and finds that the patient has a double pulse. Which condition does the nurse document in the patient's case report? Pulsus bigeminus Pulsus alternans Pulsus bisferiens Pulsus paradoxus
Pulsus bisferiens Rationale The presence of a double pulse over the carotid artery indicates that the patient has pulsus bisferiens. The patient with pulsus bisferiens has two strong systolic peaks with a dip in between, because of the backflow of the blood. It is most commonly associated with aortic valve stenosis. Pulsus bigeminus is characterized by the presence of an early heartbeat that is followed by a premature beat. If the patient has a regular rhythm along with an alternate strong and weak heartbeat, then it indicates that the patient has pulsus alternans. If the patient's pulse is weak during inspiration and strong during expiration, then it indicates that the patient has pulsus paradoxus. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 530
The primary health care provider instructs the nurse to determine the ankle-brachial index (ABI) in a patient to know the severity of peripheral artery disease (PAD). Which conditions should the nurse check for in the patient's medical record before determining the ABI? <p>The primary health care provider instructs the nurse to determine the ankle-brachial index (ABI) in a patient to know the severity of peripheral artery disease (PAD). Which conditions should the nurse check for in the patient’s medical record before determining the ABI? </p> Gastric ulcer Renal failure Hypothyroidism Diabetes mellitus Hepatic cirrhosis
Rationale Patients with renal failure and diabetes mellitus may have calcified arteries, which are noncompressible. Noncompressibility of the calcified arteries may result in increased pressure inside the arteries. Therefore, the patient may have high ankle pressure, and this may lead to false ABI results. Therefore, to ensure accurate measurement of the ABI, the nurse should check for renal failure and diabetes mellitus in the patient. Gastric ulcer, hypothyroidism, and hepatic cirrhosis do not cause calcification of the arteries and will not alter the ABI results. Therefore, the nurse does not need to check whether the patient has gastric ulcer, hypothyroidism, or hepatic cirrhosis. p. 525
Which disorders can cause calcification of the arteries? <p>Which disorders can cause calcification of the arteries? </p> Arthritis Renal failure Diabetes mellitus Hyperthyroidism Hepatic failure
Renal failure Diabetes mellitus Rationale Diabetes mellitus is associated with polyuria, which causes loss of fluids and electrolytes. This results in the calcification of the arteries. Renal failure may impair fluid and electrolyte balance causing calcification of the arteries. Hyperthyroidism, arthritis, and hepatic failure are not associated with loss of fluid and electrolyte imbalance. These medical conditions cause hypertension, joint pains, and alterations in metabolism, respectively, but they do not cause calcification of the arteries. p. 533
The nurse documents the pulse of the patient as weak and thready (1+). Which conditions in the patient does the nurse identify as the reason for such findings? Shock Fever Anemia Anxiety Peripheral artery disease (PAD)
Shock Peripheral artery disease (PAD) Rationale A weak, thready pulse (1+) occurs with shock and PAD. This is because shock and PAD may result in a decreased heart rate, thereby decreasing the pulse rate. Full, bounding pulses (3+) occur during hyperkinetic states such as fever and anxiety. They also occur if the patient is anemic. This is because these conditions are associated with an increase in pulse rate. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 517
Which actions may aggravate the symptoms of venous insufficiency? Lying Sitting Walking Elevation Prolonged standing
Sitting Prolonged standing Rationale Venous diseases cause the signs and symptoms of metabolic waste buildup. Sitting and prolonged standing interfere with blood flow and inhibit the return of the blood to and movement away from the heart and to various tissues. These actions result in blood pooling in the lower extremities of the body. Therefore, these two conditions further aggravate the disease. Lying, walking, and elevation relieve the signs and symptoms of venous diseases. p. 512
The nurse is caring for a patient who has brawny edema and unilateral swelling. The nurse finds that the patient has heavy arms and gets tired easily. Which nursing intervention will help to alleviate these signs and symptoms? <p>The nurse is caring for a patient who has brawny edema and unilateral swelling. The nurse finds that the patient has heavy arms and gets tired easily. Which nursing intervention will help to alleviate these signs and symptoms? </p> Suggesting the patient take complete bed rest Suggesting the patient use nonelastic garments Suggesting the patient use compression garments Advising the patient to perform deep breathing exercises Advising the patient to perform decongestive physiotherapy
Suggesting the patient use nonelastic garments Advising the patient to perform deep breathing exercises Advising the patient to perform decongestive physiotherapy Rationale The presence of brawny edema, heavy arms, tiredness, and unilateral swelling indicates that the patient has early lymphedema. It is associated with the accumulation of lymph in the interstitial spaces resulting in tissue damage. In order to reduce the swelling, the nurse should advise the patient to use nonelastic garments and compression garments. Decongestive physiotherapy helps to remove the excess of lymph accumulated in the arm and relieves edema. Prolonged bed rest may worsen the patient's symptoms by increasing the accumulation of fluids. Therefore, the nurse should not suggest that the patient take complete bed rest. Deep breathing exercises would help to relieve anxiety and pulmonary disorders, but these interventions do not help to drain the lymph or reduce the edema. p. 531
The nurse is assessing a patient with cyanosis who has numbness and bluish discoloration of the skin. Which other signs and symptoms in the patient would support the diagnosis of Raynaud's phenomenon? Swelling in the arms Paleness of the palms Burning pain in the arms Increased blood pressure Increased body temperature
Swelling in the arms Burning pain in the arms Rationale Raynaud's phenomenon is a peripheral vascular disease in the arms that is associated with impaired blood supply and changes in skin color. Impaired blood supply causes reduced venous return and accumulation of fluid, leading to swelling in the arms. The patient may also feel numbness and burning because of reduced blood supply. Pallor is due to arteriospasm and reduced blood supply. These changes can be seen during the first stage of the disorder but not after the second stage. Because the patient is in the second stage, as evidenced by numbness and cynosis, the nurse would not find paleness of the palms. Raynaud's phenomenon is associated with vasodilation that leads to a decrease in blood pressure, not an increase in blood pressure. Patients with Raynaud's phenomenon may have reduced body temperature due to cold, but not an increase in body temperature. p. 531
The nurse is preparing a patient for a modified Allen test. What action should the nurse take while performing the test? Instruct the patient to depress and blanch the nail beds Have the patient rotate the fingers of the hand Ask the patient to open the hand and hyperextend Tell the patient to blanch the hand by making a fist several times
Tell the patient to blanch the hand by making a fist several times Rationale The nurse instructs the patient to make a fist several times, because this action helps to occlude the radial and ulnar arteries firmly and causes the hand to blanch. The nurse instructs the patient to depress and blanch the nail beds while performing the profile sign test. The nurse does not instruct the patient to rotate the fingers of the hand, because it will not allow uniform release of pressure. The nurse instructs the patient to open the hand without hyperextending, because hyperextension may cause more pressure on the radial artery. p. 518
Which arteries are described as superficial and deep palmar arches? Ulnar artery Radial artery Plantar artery Femoral artery Popliteal artery
Ulnar artery Radial artery Rationale The brachial artery in the arm bifurcates into the ulnar and radial arteries immediately below the elbow. These arteries run distally and form two arches supplying oxygenated blood to the hand. Therefore, the ulnar and radial arteries are described as the superficial and deep palmar arches. The plantar, femoral, and popliteal arteries are associated with the leg, and they are not found in the upper extremities. These arteries are not described as superficial and deep palmar arches. p. 509
What is a characteristic of the great saphenous vein? The great saphenous vein is located inside the leg. The great saphenous vein ascends in front of the lateral malleolus. The great saphenous vein descends along the medial side of the thigh. The great saphenous vein starts on the lateral side of the dorsum of the foot.
The great saphenous vein is located inside the leg. Rationale The great and small saphenous veins are the superficial veins of the legs. The great saphenous vein is located inside the leg. The great saphenous ascends in front of the medial malleolus, not the lateral malleolus. Then it crosses the tibia obliquely. The great saphenous vein does not descend, but ascends along the medial side of the thigh. The great saphenous vein starts on the medial side of the dorsum of the foot, not the lateral side of the dorsum of the foot. Test-Taking Tip: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience. p. 510
While assessing the lymph nodes of an infant, the nurse finds that the cervical nodes are enlarged, warm, and tender on palpation. What does the nurse infer from this finding? The infant has a hand infection. The infant has an anterior chest infection. The infant has a diaper rash infection. The infant has a respiratory infection.
The infant has a respiratory infection. Rationale If the palpable lymph nodes in the infant appear small, mobile, firm, and nontender, these nodal characteristics indicate that the infant had an infection in the past. If the cervical nodes appear enlarged, warm, and tender on palpation, it may indicate that the infant has a respiratory infection, because the cervical nodes drain the lymph from the head and neck. Enlargement of the axillary nodes indicates a hand infection. An anterior chest infection does not cause the enlargement of lymph nodes in the cervical region. Enlargement of the inguinal nodes in the infant indicates an infection from diaper rash. p. 526
A nursing instructor is preparing a lecture about inguinal nodes of the lymphatic system. Which statements should the instructor include in the lecture? <p>A nursing instructor is preparing a lecture about inguinal nodes of the lymphatic system. Which statements should the instructor include in the lecture? </p> The inguinal nodes drain the lymph of the head and the neck. The inguinal nodes drain the lymph of the lower extremities. The inguinal nodes drain the lymph of the external genitalia. The inguinal nodes drain the lymph of the breast and upper arm. The inguinal nodes drain the lymph of the anterior abdominal wall.
The inguinal nodes drain the lymph of the lower extremities. The inguinal nodes drain the lymph of the external genitalia. The inguinal nodes drain the lymph of the anterior abdominal wall. Rationale The inguinal nodes of the lymphatic system are located in the groin. These nodes drain most of the lymph of the lower extremities, external genitalia, and anterior abdominal wall. The cervical nodes drain lymph of the head and neck, and the axillary nodes drain the lymph from the breast and upper arm. p. 513
A patient with severe leg pain has edema and weeping ulcers on the ankles. The patient tells the nurse, "My leg pain gets worse by the end of the day, but it feels a bit better when I walk or lay on the bed." What does the nurse interpret from these signs and symptoms? The patient has acute arterial pain. The patient has chronic arterial pain. The patient has chronic venous pain. The patient has acute venous pain.
The patient has chronic venous pain. Rationale Chronic venous pain manifests as edema, weeping ulcers on the ankles, and severe leg pain that worsens by the end of the day. It is caused by excess accumulation of fluid in the interstitial spaces because of prolonged standing and sitting. However, activities such as walking or lying on the bed may provide relief. The patient with acute arterial pain complains of having sudden pain, which is associated with paresthesia and poikilothermia. It may be caused by thromboembolism. Deep muscle pain in the calf, along with cramps and numbness, indicates chronic arterial pain. It can be relieved by standing for 2 minutes. An intense, sharp deep muscle pain along with red, warm swollen legs indicates acute venous pain. Test-Taking Tip: Identifying the content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same as or similar in nature to those in one or two of the options . pp. 534-535
The nurse is determining the ankle-brachial index (ABI) in a patient and finds it to be 0.85. What does the nurse deduce from this finding? The patient has mild peripheral artery disease. The patient has severe peripheral artery disease. The patient has no risk of peripheral artery disease. The patient has moderate peripheral artery disease.
The patient has mild peripheral artery disease. Rationale The ABI is the index that helps to measure the severity of peripheral artery disease (PAD). It can be determined by dividing the left average ankle pressure by the left or right highest average arm pressure. An ABI in the range of 0.90 to 0.71 indicates a mild risk of PAD. In this case, because the patient's ABI is 0.85, the nurse would conclude that the patient has mild PAD. An ABI of 0.40 to 0.30 indicates severe PAD. If a patient's ABI is more than 0.90, then it indicates that the patient has no risk of PAD. If a patient's ABI is 0.70 to 0.41, then it indicates that the patient has moderate PAD. p. 535
The nurse observes that a patient's pulse is easily palpable and pounds under the fingertips. What can the nurse infer from these findings? <p>The nurse observes that a patient’s pulse is easily palpable and pounds under the fingertips. What can the nurse infer from these findings? </p> The patient is anemic. The patient is in a hyperkinetic state. The patient may have hyperthyroidism. The patient may have decreased cardiac output. The patient may have aortic valve regurgitation.
The patient is anemic. The patient is in a hyperkinetic state. The patient may have hyperthyroidism. Rationale Anemia, a hyperkinetic state, and hyperthyroidism result in a full, bounding pulse. These conditions are associated with increased blood flow and heart rate that result in a bounding pulse. A decrease in cardiac output reduces the blood flow and results in a weak, thready pulse. A patient who has aortic valve regurgitation will have a water-hammer (Corrigan) pulse due to backflow of the blood. p. 517
The laboratory reports of a patient show that the highest right average ankle pressure is 120 mm Hg and the highest average right arm pressure is 129 mm Hg. What do these findings indicate? The patient is at mild cardiovascular risk. The patient is at severe cardiovascular risk. The patient is at moderate cardiovascular risk. The patient is at borderline cardiovascular risk.
The patient is at borderline cardiovascular risk. Rationale The ankle-brachial index (ABI) is an important tool that helps to identify whether the patient is at risk for peripheral vascular diseases such as peripheral artery disease (PAD). The ABI can be determined using the formula ABI = highest right or left average ankle pressure ( dorsalis pedis [DP] or posterior tibial [PT])/highest average right or left arm pressure. In this case, the patient's right ABI = 120/129 = 0.93. An ABI of 0.93 indicates that the patient is at borderline cardiovascular disorder risk. If the patient has an ABI ranging from 0.90 to 0.71, then the patient may have mild PAD. An ABI of 0.40 to 0.30 indicates severe PAD. An ABI of 0.70 to 0.41 indicates moderate PAD. p. 525
While performing peripheral vascular examination in a patient by using capillary refill, the nurse finds that the refill lasts for 5 seconds. What does the nurse interpret from this finding? The patient is at risk of hypoxia. The patient is at risk of hypovolemia. The patient is at risk of bilateral edema. The patient is at risk of peripheral vascular disease.
The patient is at risk of hypovolemia. Rationale The patient's capillary refill lasts for more than 2 seconds. It indicates decreased cardiac output and vasoconstriction. Decreased cardiac output may result in hypovolemic shock in the patient. Insufficient supply of oxygen or decreased hemoglobin content in the blood may result in hypoxia. The nurse cannot assess hypoxia in the patient by checking the capillary refill, so the nurse measures the site to evaluate bilateral edema. Capillary refill is not an indicator of bilateral edema. The nurse auscultates the site for a bruit to determine the presence of peripheral vascular disease in the patient. A capillary refill that lasts for more than 2 seconds is not associated with peripheral vascular disease. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 516
The nurse is finding it difficult to locate an elderly patient's pulse. After palpating the patient's arm for some time, the nurse locates the pulse but notices it is obliterated on applying pressure. What do these findings indicate? <p>The nurse is finding it difficult to locate an elderly patient’s pulse. After palpating the patient’s arm for some time, the nurse locates the pulse but notices it is obliterated on applying pressure. What do these findings indicate? </p> The patient may have hyperthyroidism. The patient may have aortic valve stenosis. The patient may have aortic valve regurgitation. The patient may have decreased cardiac output. The patient may have peripheral arterial disease.
The patient may have aortic valve stenosis. The patient may have decreased cardiac output. The patient may have peripheral arterial disease. Rationale A pulse that is difficult to locate and is obliterated on applying pressure is considered a weak and thready pulse. Aortic valve stenosis, decreased cardiac output, and peripheral arterial disease are associated with decreased blood flow and fall in blood pressure, resulting in a weak and thready pulse. Hyperthyroidism is associated with increased metabolism, and an easily palpable and full bounding pulse. Aortic valve regurgitation is associated with backflow of the blood, which results in a water-hammer (Corrigan) pulse, not a weak, thready pulse. p. 530
While assessing a patient with acute asthma, the nurse concludes that the patient may have pulsus paradoxus. Which finding supports the nurse's conclusion? The patient's pulse is easily detectable under the fingertips. The patient's blood pressure falls to 100/70 mm Hg during inspiration. The patient's blood pressure falls to 90/60 mm Hg during expiration. The patient has a premature heartbeat followed by a normal heartbeat.
The patient's blood pressure falls to 100/70 mm Hg during inspiration. Rationale A patient with acute asthma will have pericardial effusion that compresses the heart, decreases cardiac output, and causes pulsus paradoxus. Pulsus paradoxus is associated with a fall in the blood pressure more than 10 mm Hg during inspiration. Therefore, a blood pressure of 100/70 mm Hg during inspiration indicates that the patient has pulsus paradoxus. The presence of an easily detectable pulse indicates that the patient has anxiety associated with increased blood flow. Pulsus paradoxus is associated with a fall in blood pressure during inspiration but not during expiration. The presence of a premature heartbeat followed by a normal beat indicates that the patient has pulsus bigeminus. p. 532
While assessing a patient with an infection on the hand, the nurse uses one hand to shake the patient's hand and keeps the other hand near the patient's elbow. What could be the reason for the nurse's action? To check for the persistence of pallor To check for arterial insufficiency To check for enlarged axillary nodes To check for enlarged epitrochlear nodes
To check for enlarged epitrochlear nodes Rationale Local infections of the hand or forearm may trigger enlargement of the epitrochlear nodes. In this case, the nurse is assessing the presence of enlarged epitrochlear lymph nodes. The modified Allen test helps to determine the persistence of pallor, which occurs because of occlusion of the collateral arterial flow. The nurse palpates the brachial pulses to determine arterial insufficiency in the patient. The enlargement of axillary nodes may occur in patients with breast cancer. However, nodes in the axilla also enlarge in response to infections associated with the upper extremities. The nurse will not be able to identify enlarged axillary nodes with the help of this assessment. p. 518
