Ch 22 3060

A nurse obtains the following information: right arm brachial pressure, 160 mm Hg; left arm brachial pressure, 150 mm Hg; right ankle pressure, 80 mm Hg; left ankle pressure, 94 mm Hg. The nurse determines that the right ankle-brachial index would be which of the following?

0.50

A nurse is determining a client's ankle-brachial index. Which result would indicate to the nurse that the client's circulation is normal and free of arterial occlusion?

1.1

When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency?

14 year history of smoking a pack a day

Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following?

3+

An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect?

Arterial insufficiency

During a health visit, a client says, I know that arteries and veins are both blood vessels, but what's the difference?î Which of the following would the nurse include in the response?

Arteries have thicker walls than veins

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. Which of the following would be most appropriate for the nurse to do next?

Compare measurements of both extremities

While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply.

Deep Circular in shape Client report of severe pain

The nurse has attempted to palpate the client's popliteal pulses but is unable to feel them, despite confirming appropriate landmarking and client positioning. What is the nurse's best response?

Document the finding and proceed with the assessment.

The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test?

Document the lack of potency in the ulnar and/or radial arteries.

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next?

Document this finding as normal.

The nurse is assessing a client who has been referred to the clinic because of possible arterial insufficiency. What assessment finding should the nurse identify as most consistent with this diagnosis?

Dry, shiny, hairless shines and feet

A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next?

Examine the lower arm and hand for infection sites

During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse?

Femoral

The nurse is assessing an 81-year-old client's peripheral vascular function. What principle should guide the nurse's analysis of assessment data?

Hair loss on the legs may be an age-related change rather than a sign of arterial insufficiency.

When assessing a client for possible varicose veins, the nurse should do which of the following actions?

Have the client stand for the exam

Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease?

Have you experienced a change in your usual sexual activities?

The nurse is using Doppler ultrasound to auscultate the peripheral pulses of a client with peripheral vascular disease. What action should the nurse perform during this assessment?

Hold the probe at a 60- to 90-degree angle to the client's skin.

A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most appropriate action?

Palpate the brachial pulse

A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique?

Students compress the clients nail bed until it blanches.

The presence of faint pedal pulses in a client has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client may have arterial insufficiency?

The client's legs are visibly pale when elevated above the examination table.

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

The client's toe is receiving an inadequate supply of blood.

The nurse reads in a client's electronic health record that her most recent ankle-brachial index (ABI) was 0.42. How should this assessment finding inform the nurse's care?

The nurse should implement interventions to address severe arterial insufficiency.

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

Ulnar

A group of nursing students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes?

Upper abdomen

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area?

Upper arm

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next?

Use doppler ultrasonography to locate pulse

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?

Venous insufficiency

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?

Venous insufficiency

The clinic nurse is reviewing the medication history of a 39-year-old woman. Which medication would the nurse identify as a potential risk factor for thrombophlebitis?

an oral contraceptive