Ch. 22 Vascular System (Prep U)

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 4-mm depression. How would the nurse document this? a) +1 pitting edema b) +2 pitting edema c) +3 pitting edema d) +4 pitting edema

+2 pitting edema Explanation: Slight pitting edema, with a 2-mm depression is +1. Increased pitting with a 4-mm depression is +2. Deeper pitting with a 6-mm depression is +3 and severe pitting has an 8-mm depression.

If palpable, superficial inguinal nodes are expected to be: a) Nontender, mobile, and 1 cm in diameter b) Fixed, nontender, and 1.5 cm in diameter c) Fixed, tender, and at 2.5 cm in diameter d) Discrete, tender, and 2 cm in diameter

a) 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.

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) Cool leg on one side b) Cool legs bilaterally c) Cold fingers and hands d) Capillary refill less than 2 seconds

c) Cold fingers and hands

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

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

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) Place the second hand 3 to 4 inches above the first hand c) Firmly compress the lower portion of the varicose vein d) Feel for a pulsation to the fingers in the lower hand

c) Firmly compress the lower portion of the varicose vein

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

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's a) femoral pulse. b) popliteal pulse. c) brachial pulse. d) tibial pulse.

c) brachial pulse

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

c) brisk, expected (normal) pulse

An older client is hospitalized with pneumonia. The nurse suspects the client is developing severe sepsis based on which assessment findings? (Select all that apply.) a) Temperature 37.8 degrees Celsius b) Pulse 104 beats/minute c) White blood cell count 10,000/mm3 d) Platelet count 90,000 e) PaCO2 30 mmHg

• Platelet count 90,000 • Pulse 104 beats/minute • PaCO2 30 mmHg Explanation: Inital signs of severe sepsis include: heart rate greater than 90 beats/min; platelet count less than 100,000; temperature less than 36 or greater than 38.3 degrees Celsius; PaCO2 less than 32 mmHg; white blood cells greater than 12,000 or leass than 4,000 mm3.

The nurse explains to the client with a diagnosis of peripheral vascular disease her is at risk for what occurring? Select all that apply. a) Hypertension b) Stroke c) Obesity d) Diabetes e) Myocardial infarction

• Stroke • Myocardial infarction

The radial pulse is palpated over the lateral flexor surface. a) False b) True

True

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) malignancy. b) localized infection. c) arterial insufficiency. d) systemic infection.

a) malignancy.

While assessing the legs of your patient you note that the legs and feet are cool to the touch. What would you know is most often the cause of bilateral coolness? a) DVT b) Anxiety c) Embolism d) Inadequate arterial circulation

b) Anxiety

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

b) 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? a) Raise the foot of the bed for an hour and then lower it. b) Assist the client to walk as soon and as often as possible. c) Assist in active range-of-motion exercise of the upper body. d) Massage lower extremities vigorously every 6 hours.

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

The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment? a) Education on nonmodifiable risk factors b) Identification of cardiovascular risk factors c) Plan for modifying risk factors d) History related to grandparents' health

b) Identification of cardiovascular risk factors

A nurse is working with a client who demonstrates venous stasis in his legs. The nurse understands that there must be a problem with one of the mechanisms of venous function that help to propel blood back to the heart. Which of the following are included among these mechanisms? Select all that apply. a) Gravity b) One-way valves in the veins c) Pumping action of the heart d) Pressure gradient produced by inspiration e) Skeletal muscle contraction

b) One-way valves in the veins e) Skeletal muscle contraction d) Pressure gradient produced by inspiration

Which vessels return the lymph fluid to circulation? a) Epitrochlear ducts b) Thoracic ducts c) Internal jugular ducts d) Infraclavicular ducts

b) Thoracic ducts

The nurse is testing the valvular competency of the saphenous system. What test is the nurse performing on the patient? a) Venous occlusion test b) Trendelenburg test c) Ankle-brachial index test d) Allen test

b) Trendelenburg test

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching? a) Wear compression stockings at all times. b) Report any changes in skin or hair appearance to health care provider. c) Check feet daily for cuts or pressure areas. d) Disfigurement is common in clients with peripheral arterial disease.

c) Check feet daily for cuts or pressure areas.

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

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

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) Shortness of breath b) Knee pain c) Chest pressure with exertion d) Intermittent claudication

d) 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? a) Pulmonary embolism b) Deep vein thrombosis c) Varicose veins d) Intermittent claudication

d) Intermittent claudication

A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding? a) Head and neck for recent ear infection or sore throat b) Cervical lymph nodes for tenderness and swelling c) Abdomen, noting any organ enlargement or tenderness d) Lower arm and hand for erythema and swelling

d) Lower arm and hand for erythema and swelling

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

d) Palpate both radial arteries for symmetry.

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) Venous disease c) Neuropathy secondary to diabetes 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 temperature b) Marked edema c) Normal pulsation d) Thin, shiny, atrophic skin

d) Thin, shiny, atrophic skin

After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? a) iliofemoral b) communicating c) saphenous d) popliteal

d) 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 ulcers. b) ankle edema. c) arterial occlusive disease. d) venous insufficiency.

d) venous insufficiency