Prep U CH 22

When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause

Peripheral arterial disease

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

Assess adequacy of blood flow using a Doppler device.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis

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

The RN caring for a newly admitted client after central-line placement should complete which priority assessment

Auscultate lung sounds bilaterally

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for

Peripheral vascular problems

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

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

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person

1.00

Which of the following clients is most likely at the greatest risk of acute compartment syndrome

A 17-year-old who has just been fitted with an arm cast following a fracture of his radius

Which of the following wounds is most likely attributable to neuropathy

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

A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding

Abdomen, noting any organ enlargement or tenderness

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion

Allen test

What is a long-term complication of peripheral vascular disease

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

Ankle-brachial index (ABI) Explanation: The ABI is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Approximately 16% of clients with known peripheral vascular disease also have coronary artery disease.

The nurse is assessing blood flow in the lower extremities of a client. What should the nurse keep in mind when using a Doppler for this assessment? Select all that apply.

Apply warm gel to the areas on the extremity Apply steady but gentle pressure over the area Keep the extremity warm during the assessment

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

Arterial occlusion

When assessing temperature of the skin, which portion of the hand should the examiner use

Back of Fingers

A nurse is caring for a client diagnosed with chronic lymphedema. In preparing a teaching plan for this client, what would be essential for the nurse to address when considering psychosocial wellness

Body image

Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward

Brachial

The nurse is assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the client's pain be most concerning

Calf

The client is experiencing septic shock. What assessment finding would the nurse expect to find

Capillary refill greater than 2 seconds Explanation: The client experiencing septic shock would have a capillary refill greater than 2 seconds. The temperature may or many not be normal, blood pressure would be low and extremities would be cool

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action

Check the insertion site for redness.

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find

Cold fingers and hands

The nurse notes that a client has a history of peripheral arterial disease. What should the nurse expect when assessing this client? Select all that apply.

Cold skin over the feet Toe wound that will not heal Pain in the calves when walking

The nurse is suspicious of a deep vein thrombosis (DVT) in a client's right calf area. Which actions should the nurse perform or assist with to aid in the diagnosis of DVT? (Select all that apply.)

Complete Wells Score System Draw labwork for D-dimer Prepare client for venous duplex scan Measure calf size in both legs

Which of the following assessment findings is most congruent with chronic arterial insufficiency

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

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency

Cool skin Explanation: A cool extremity may be a sign of arterial insufficiency.

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease

Diabetes

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action

Elevate the legs on pillows.

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client

Extent of tobacco use and exposure

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

False

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

Firmly compress the lower portion of the varicose vein

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

Immobility

A nurse palpates a weak left radial artery on a client. What should the nurse do next

Palpate both radial arteries for symmetry.

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

Intermittent claudication

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

Intermittent claudication

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test

Legs should be elevated for 15 seconds

A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next

Lightly palpate the client's leg veins for tenderness

What mechanisms produce edema? (Select all that apply.)

Low plasma protein levels Capillary leak syndrome Increased capillary blood pressure

If palpable, superficial inguinal nodes are expected to be:

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

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate

Normal finding

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

Peripheral arterial disease

The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate

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

A 55-year-old secretary with a recent history of breast cancer, for which she underwent surgery and radiation therapy, and hypertension comes to the office for a routine check-up. Which of the following aspects of the physical examination are most important when assessing the client for peripheral vascular disease in the arms

Radial pulse, brachial pulse

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply.

Respiration Intraluminal valves Skeletal muscle contraction

The nurse assessing the client's skin identifies an ulcer. What would indicate to the nurse it is a venous ulcer

The ulcer is superficial and pale.

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease

Thin, shiny, atrophic skin

The nurse is preparing discharge teaching for a patient diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include

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

The radial pulse is palpated over the lateral flexor surface

True

Which nursing assessment finding supports the diagnosis of chronic arterial insufficiency

Ulceration is noted on the great toe of the affected foot.

Which of the following veins drain into the superior vena cava? (Mark all that apply.)

Upper extremities Upper torso Head

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

Venous insufficiency

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely

Venous insufficiency

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what

Venous thromboembolism

The posterior tibial pulse can be palpated at the

ankle.

The largest arteries of the upper extremities are the

brachial arteries

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the

competence of the saphenous vein valves.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder

deep vein thrombosis Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis.

A client tells a nurse that she has been experiencing intermittent episodes of numbness, tingling, pain, and burning in the fingertips, especially after being cold. What is an appropriate question for the nurse to ask the client to further assess this occurrence

do you notice your fingers changing colors?

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

lymphedema.

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded

popliteal

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

right cervical node The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct.

A client's ankle-brachial index is 0.70. What should this finding suggest to the nurse about the client's peripheral vascular integrity

there is borderline perfusion to the lower extremities

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client

venous insufficiency

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

venous insufficiency.