PrepU - Chapter 22: Assessing Peripheral Vascular System

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. - Cigarette smoking - Regular exercise - Stress-reduction techniques - Low alcohol intake - Previous use of hormones - High-fat diet

- Cigarette smoking - Previous use of hormones - High-fat diet

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

- Smoking - Overweight - Lack of exercise

A nurse is working with a patient who has been confined to bed rest in the hospital for the past 2 weeks. Which areas of the body are most likely to develop ulcers due to arterial insufficiency? Select all that apply. - Tips of toes - Medial ankle - Toe webs - Heels - Anterior tibial area

- Toe webs - Heels - Tips of toes

Which of the following veins drain into the superior vena cava? (Mark all that apply.) - Lower extremities - Upper torso - Head - Upper extremities - Lower torso

- Upper torso - Head - Upper extremities

The RN caring for a newly admitted client after central-line placement should complete which priority assessment? A. Auscultate lung sounds bilaterally B. Reconcile all home medications C. Capillary refill of extremeties D. Signs of infection at insertion site

A. Auscultate lung sounds bilaterally

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. Cold fingers and hands B. Cool legs bilaterally C. Cool leg on one side D. Capillary refill less than 2 seconds

A. Cold fingers and hands

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? A. Immobility B. Obesity C. Smoking D. Hypertension

A. Immobility

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. Chest pressure with exertion C. Shortness of breath D. Knee pain

A. Intermittent claudication

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? A. Legs should be elevated for 15 seconds B. Tourniquet should be put on before leg elevation C. Have the client stand upright after tourniquet removal D. Ensure that the client's legs are over the side of the bed

A. Legs should be elevated for 15 seconds

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

A. Lymphedema

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

A. Palpate both radial arteries for symmetry.

When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause? A. Peripheral arterial disease B. Chronic lymphedema C. Venous insufficiency D. Arterial aneurysm

A. Peripheral arterial disease

What pulse is located in the groove between the medial malleolus and the Achilles tendon? A. Posterior tibial B. Dorsalis pedis C. Popliteal D. Femoral

A. Posterior tibial

The nurse assessing the client's skin identifies an ulcer. What would indicate to the nurse it is a venous ulcer? A. The ulcer is superficial and pale. B. The ulcer is necrotic. C. The client voices pain related to the ulcer. D. The extremity is without a pulse.

A. The ulcer is superficial and pale.

The radial pulse is palpated over the lateral flexor surface. A. True B. False

A. True

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

A. brisk, expected (normal) pulse

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

A. deep vein thrombosis

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? A. popliteal B. iliofemoral C. saphenous D. communicating

A. popliteal

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. arterial occlusive disease. C. venous ulcers. D. ankle edema.

A. venous insufficiency.

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. Arterial occlusion

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

B. Assess adequacy of blood flow using a Doppler device.

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. Capillary refill greater than 2 seconds

Walking contracts the calf muscles and forces blood away from the heart. A. True B. False

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

B. Firmly compress the lower portion of the varicose vein

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? A. Obstruction in the femoral artery B. Peripheral vascular problems C. Diabetes mellitus D. Calcium deficiency

B. Peripheral vascular problems

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

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

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. Arterial insufficiency B. Venous insufficiency C. Intermittent claudication D. Hypertrophic changes

B. Venous insufficiency

The nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing A. varicose veins. B. intermittent claudication. C. edema. D. thrombophlebitis.

B. intermittent claudication.

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

B. right cervical node

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

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

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

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. Venogram B. CT scan of the lower legs C. Ankle-brachial index (ABI) D. PET scan

C. Ankle-brachial index (ABI)

When assessing temperature of the skin, which portion of the hand should the examiner use? A. Fingertips B. Palms C. Backs of fingers D. Ulnar aspect of the hand

C. Backs of fingers

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? A. Have the client sit down B. Use a Doppler ultrasound device on the client's leg C. Lightly palpate the client's leg veins for tenderness D. Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe

C. Lightly palpate the client's leg veins for tenderness

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

C. Nontender, mobile, and 1 cm in diameter

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

C. venous insufficiency

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

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

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.

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

D. Brachial

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

D. Check the insertion site for redness.

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

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

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

D. Notify the healthcare provider.

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. Neuropathy secondary to diabetes C. Venous disease D. Peripheral arterial disease

D. Peripheral arterial disease

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? A. Normal pulsation B. Normal temperature C. Marked edema D. Thin, shiny, atrophic skin

D. Thin, shiny, atrophic skin

The major artery that supplies blood to the arm is the A. radial artery. B. ulnar artery. C. posterior artery. D. brachial artery.

D. brachial artery.

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with A. localized infection. B. systemic infection. C. arterial insufficiency. D. malignancy.

D. malignancy.