HA -- Ch. 15

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

1.00

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

Research has found that there is a dramatic increase in the incidence of peripheral arterial disease during what time period in a person's life?

7th and 8th decades

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

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

The nursing instructor is discussing the great and small saphenous veins. What would the instructor say connects these two veins?

Anastomotic veins

An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect?

Arterial insufficiency

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. What would the nurse suspect?

Arterial insufficiency

During an assessment, the nurse first performs the action shown. After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing?

Arterial insufficiency

The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate?

Behind the ankle

When describing the major arteries of the arms and legs, which of the following would the instructor identify as the major supplier of blood to the arms?

Brachial artery

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

It filters harmful substances from the body.

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.

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

Cigarette smoking

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

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 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

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

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

Have the client stand for the exam

The nurse is assessing a client for varicose veins. Which action, by the nurse is appropriate?

Have the client stand for the exam.

The nurse is discussing risk factors of an aneurysm. What should be included? Select all that apply.

Hypertension,Smoking,Family history

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 client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?

Lymphedema

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

The nurse is concerned that a client has poor circulation in the right hand. What finding caused the nurse to have this concern?

Pallor when the ulnar artery is occluded

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

Palpate both radial arteries for symmetry.

A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next?

Palpate the brachial pulse.

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

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 nurse experiences difficulty in palpating the popliteal pulses in a client during assessment of the peripheral vascular system. What should the nurse do to assist in locating this pulse on a client?

Place the client in the prone position.

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

Posterior tibial

A client seeks medical attention for the condition shown. What finding does the nurse anticipate?

Raynaud's disease

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.

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

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 radial pulse is palpated over the lateral flexor surface.

True

A group of 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

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

Use Doppler ultrasonography to locate the pulse.

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 posterior tibial pulse can be palpated at the

ankle.

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing

arterial insufficiency.

In diagnosing a bigeminal pulse, the nurse would expect (Select all that apply.)

normal beat,premature contraction,diminished stroke volume

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

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.