HA Exam 3

A pulse readily or easily to obliterate is

1+ (weak, thread pulse)

the nurse is assessing a client's pulse, and feels a pulse that is hand to palpate, fades in and out, easily obliterated by pressure. the nurse documents this pulse as:

1+ weak

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? A) 0.50 B) 0.53 C) 0.59 D) 0.63

A) 0.50

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? A) Arterial insufficiency B) Musculoskeletal weakness C) Venous insufficiency D) Diabetic neuropathy

A) Arterial insufficiency

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what is the difference?" Which of the following would the nurse include in the response? A) Arteries have thicker walls than veins. B) Arteries carry 70% of the body's blood volume. C) Arteries have a lower pressure than veins. D) Arteries carry waste from the tissues.

A) Arteries have thicker walls than veins.

A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? A) Caucasian B) African American C) South Asian D) Native American

A) Caucasian

A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weight is 120 pounds. After determining the client's percentage of ideal body weight, which of the following should the nurse conclude? A) Client is mildly malnourished. B) Client is experiencing moderate malnutrition. C) Severe malnutrition is present. D) The client's body weight is within 10% of ideal body weight.

A) Client is mildly malnourished.

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? A) Compare measurements of both extremities. B) Perform the Allen test. C) Check for bilateral varicosities. D) Palpate the femoral pulses.

A) Compare measurements of both extremities.

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? A) Document this finding as normal. B) Recheck in 5 minutes after elevating the arm. C) Reassess after applying warm compresses. D) Refer the client for medical follow-up.

A) 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? A) Dry, shiny, hairless shins and feet B) Pitting edema to the feet and ankles C) Numbness and tingling of the lower extremities D) Reddish-blue coloration of the shins and feet

A) Dry, shiny, hairless shins and feet

The nurse should prioritize assessments related to overhydration for a client experiencing which of the following health problems? A) Early congestive heart failure B) Chronic emphysema C) Newly diagnosed hepatitis C virus infection D) Adult respiratory distress syndrome

A) Early congestive heart failure

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect? A) Gouty arthritis B) Rheumatoid arthritis C) Degenerative joint disease D) Plantar fasciitis

A) Gouty arthritis

When assessing a client for possible varicose veins, the nurse should do which of the following actions? A) Have the client stand for the exam. B) Tell the client to raise his or her leg. C) Dorsiflex the client's foot. D) Obtain the ankle-brachial index.

A) Have the client stand for the exam.

The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which of the following would be the best example? A) Health-seeking behaviors related to desire and request to alter amount of food intake B) Imbalanced nutrition: less than body requirements related to inadequate caloric intake C) Imbalanced nutrition: more than body requirements related to excessive caloric intake D) Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue

A) Health-seeking behaviors related to desire and request to alter amount of food intake

When evaluating nutrition in an adult female client, which laboratory value would most concern the nurse? A) Hemoglobin A1c of 9% B) Serum albumin of 4.9 g/dL C) Total protein of 6.7 g/dL D) Hematocrit of 39%

A) Hemoglobin A1c of 9%

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect? A) Meningitis B) Cervical strain C) Compression fracture D) Cervical disc degeneration

A) Meningitis

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes

A) Numbness

Assessment reveals that an older adult client has osteomalacia. Which of the following would be most important to include in the client's teaching plan? A) Practice risk prevention for fractures. B) Keep exercise to a minimum to decrease pain. C) Minimize movements to maintain joint stability. D) Treat secondary arthritis proactively.

A) Practice risk prevention for fractures.

The nurse is assessing a client who has been admitted with signs and symptoms that are consistent with malnutrition. Which of the following physiological phenomena would the nurse recognize as an early indicator of malnutrition? A) Protein stores are lower than normal B) Bone is metabolized to compensate for missing nutrients C) Calcium levels decrease D) Hemoglobin levels decrease

A) Protein stores are lower than normal

Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination B) Imbalanced nutrition: more than body requirements related to diabetes C) Potential complication: hypertension D) Powerlessness related to diabetes self-care and management

A) Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination

The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply. A) Risk for injury related to osteoporosis B) Risk for infection related to osteoporosis C) Activity intolerance related to osteoporosis D) Impaired physical mobility related to osteoporosis E) Disturbed sensory perception related to osteoporosis

A) Risk for injury related to osteoporosis C) Activity intolerance related to osteoporosis D) Impaired physical mobility related to osteoporosis

Which test would be most appropriate for the nurse to perform when a client complains of low back pain? A) Straight leg test B) Muscle leg strength C) Lateral bending of cervical spine D) Internal rotation of the shoulders

A) Straight leg test

The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? A) Teaching the client muscle-building exercises B) Discussing ways to increase body fat stores C) Assisting client in reducing the amount of fluid build-up D) Encouraging the use of a multivitamin supplement

A) Teaching the client muscle-building exercises

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? A) Ulnar B) Radial C) Brachial D) Femoral

A) Ulnar

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? A) Venous insufficiency B) Stasis ulceration C) Arterial occlusion D) Dependent edema

A) 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? A) Venous insufficiency B) Peripheral edema C) Coronary artery disease D) Raynaud's phenomenon

A) Venous insufficiency

The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination? A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation B) Whether the size of the client's knee changes throughout the joint's range of motion C) Whether swelling in the knee joint is a normal age-related change or a pathological finding D) Whether the client's knee joint is capable of adduction and abduction

A) Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation

The nurse is providing care to a client with venous insufficiency. A skin ulcer associated with vein found on which area of the lower extremities?

Ankle of the leg

During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? A) "The majority of your diet should consist of whole grains." B) "Choose low-fat versions of milk products such as yogurt." C) "Drink at least 2 to 3 glasses of fruit juices a day." D) "Eat fewer orange vegetables and more dark green vegetables daily."

B) "Choose low-fat versions of milk products such as yogurt."

A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount? A) 0.5 liters B) 1.0 liters C) 1.5 liters D) 2.0 liters

B) 1.0 liters

A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis? A) A 71-year-old man who has type 2 diabetes B) A 69-year-old woman with no major risk factors for osteoporosis C) A 37-year-old woman who takes oral contraceptives D) A 49-year-old African-American woman who is obese

B) A 69-year-old woman with no major risk factors for osteoporosis

When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next? A) Move the part passively through its range of motion. B) Ask the client to move the part against gravity. C) Inspect by touch for a palpable contraction of the muscle. D) Percuss the client's shoulder joint

B) Ask the client to move the part against gravity.

A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status? A) Flat, firm abdomen B) Brittle hair C) Pink mucous membranes D) Elastic skin

B) Brittle hair

During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density? A) Beta-adrenergic blockers B) Corticosteroids C) Nonsteroidal anti-inflammatories (NSAIDs) D) Calcium channel blockers

B) Corticosteroids

The nurse is conducting a focused musculoskeletal assessment of an older adult client. When analyzing assessment data, the nurse should be aware of what age-related physiological changes? Select all that apply A) Absence of knee flexion B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength

B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength

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. A) Irregular border B) Deep C) Circular in shape D) Moderate leg edema E) Client report of severe pain

B) Deep C) Circular in shape E) Client report of severe pain

A nurse is assessing a client for possible fluid overload. Which of the following assessment findings is most consistent with this diagnosis? A) Venous filling of 3 seconds B) Distended neck veins with head elevated at 45 degrees C) Moist, plump tongue D) Boggy eyeball

B) Distended neck veins with head elevated at 45 degrees

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? A) Document the absence of dorsalis pedis or posterior tibial pulses. B) Document the lack of patency in the ulnar and/or radial arteries. C) Attempt to palpate the popliteal pulse with the client's leg in a dependent position. D) Corroborate the finding by assessing capillary refill in the client's great toes.

B) Document the lack of patency in the ulnar and/or radial arteries.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? A) Hard and fixed cervical nodes B) Enlarged and tender inguinal nodes C) Bilateral enlargement of the popliteal nodes D) Pelletlike nodes in the supraclavicular region

B) Enlarged and tender inguinal nodes The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation

B) Flexion

The nurse is assessing an 81-year-old client's peripheral vascular function. What principle should guide the nurse's analysis of assessment data? A) Leg pain that is relieved by rest is the result of normal physiological changes. B) Hair loss on the legs may be an age-related change rather than a sign of arterial insufficiency. C) Venous ulcers and arterial ulcers have a similar appearance and course in older adults. D) Non-palpable peripheral pulses are expected in clients over the age of 80.

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

Inspection of a client's foot reveals an enlarged, painful, inflamed bursa (bunion) on the medial side of the foot. The nurse should make a referral for what health problem? A) Osteomalacia B) Hallux valgus C) Pes planus D) Gouty arthritis

B) Hallux valgus

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following? A) Compact bone B) Red marrow C) Yellow marrow D) Spongy bone

B) Red marrow

When asked to touch her ear to her shoulder, a client reports pain. Which of the following should the nurse do next? A) Perform muscle strength against resistance. B) Refer the client for further evaluation. C) Flex and then hyperextend the neck. D) Palpate the paravertebral muscles for pain.

B) Refer the client for further evaluation.

A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique? A) Student gently compresses the wrist area on the side of the thumb. B) Student compresses the client's nail bed until it blanches. C) Student applies firm pressure to the hand, noting any indentation. D) Student asks client to turn hands slowly over and back.

B) Student compresses the client's 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? A) The client's legs are tender on palpation when in a dependent position. B) The client's legs are visibly pale when elevated above the examination table. C) The client's legs return to a pink color in 5 seconds. D) The client's legs develop pitting edema when he or she dangles them over the bedside.

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

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? A) The nurse should inspect the client's feet and ankles for venous ulcers once per shift. B) The nurse should implement interventions to address severe arterial insufficiency. C) The nurse should assess the client's extremities for pitting edema at least once per shift. D) The nurse should position the client to promote venous return.

B) The nurse should implement interventions to address severe arterial insufficiency.

The nurse is preparing to perform a nutritional assessment of a newly admitted client. Which of the following questions would be most appropriate to use when initiating the assessment? A) "Did you eat breakfast today?" B) "How many meals do you eat each day?" C) "Can you tell me what you've eaten in the last 24 hours?" D) "How often do you eat out?"

C) "Can you tell me what you've eaten in the last 24 hours?"

Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease? A) "What dietary supplements do you take?" B) "When was your last prostate exam for cancer?" C) "Have you experienced a change in your usual sexual activity?" D) "Have you had an electrocardiogram recently?"

C) "Have you experienced a change in your usual sexual activity?"

When obtaining the nutritional health history from a female client, which of the nurse's questions would best elicit information about the client's knowledge of her own health status? A) "Are you now or have you been on a diet recently?" B) "How much fluid do you drink in a day?" C) "What are your height and usual weight?" D) "Can you tell me what you consider to be a healthy meal?"

C) "What are your height and usual weight?"

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? A) 0.5 B) 0.8 C) 1.1 D) 1.4

C) 1.1

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? A) 1+ B) 2+ C) 3+ D) 4+

C) 3+

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5

C) 4/5

A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluid balance. The nurse should include insensible fluid losses of what volume when performing this assessment? A) 100 to 300 mL B) 450 to 650 mL C) 800 to 1000 mL D) 1200 to 1400 mL

C) 800 to 1000 mL

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? A) A beta-adrenergic blocker B) A selective serotonin reuptake inhibitor (SSRI) C) An oral contraceptive D) An antilipid agent

C) An oral contraceptive

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion? A) Phalen's test B) Tinel's test C) Ballottement test D) Leg raising test

C) Ballottement test

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? A) Osteoarthritis B) Diabetic neuropathy C) Carpal tunnel syndrome D) Gouty arthritis

C) Carpal tunnel syndrome

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? A) Advocate for a referral to a vascular surgeon. B) Have the client perform light physical activity to promote circulation and then reattempt. C) Document the finding and proceed with the assessment. D) Palpate the client's brachial pulse.

C) Document the finding and proceed with the assessment.

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? A) Ask the client about any recent ear and throat infections. B) Carefully assess the cervical lymph nodes for enlargement. C) Examine the lower arm and hand for infection sites. D) Assess both legs for Homans' sign.

C) Examine the lower arm and hand for infection sites.

Which of the following would the nurse expect to find when examining a client with a herniated lumbar disc? A) Rounded thoracic convexity B) Lumbar lordosis C) Flattened lumbar curve D) Lateral curvature of the spine

C) Flattened lumbar curve

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor? A) Obesity B) Multiparity (multiple pregnancies) C) History of smoking D) African-American ethnicity

C) History of smoking

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? A) Gently cool the client's extremities to aid auscultation. B) Apply a small amount of petroleum gel to the Doppler probe. C) Hold the probe at a 60- to 90-degree angle to the client's skin. D) Push the probe firmly against the skin to enhance audibility.

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

A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding? A) Flexion of 80 degrees B) Lateral bending of 35 degrees C) Hyperextension of 15 degrees D) Rotation of 30 degrees

C) Hyperextension of 15 degrees

A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find? A) Limitation of all shoulder motion B) Chronic pain C) Limited abduction D) Sharp catches of pain with movement

C) Limited abduction

Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder? A) Test muscle strength. B) Perform passive range of motion test. C) Measure range of motion with a goniometer. D) Ask the client which is the dominant side.

C) Measure range of motion with a goniometer.

A nurse is assessing a client's skeletal muscle mass in the context of a comprehensive nutritional assessment. Which measurement would yield the most valid and reliable data? A) Body mass index B) Triceps skin fold measurement C) Mid-arm circumference D) Waist circumference

C) Mid-arm circumference

A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most appropriate action? A) Refer the client for medical follow-up. B) Document the finding and proceed with the assessment. C) Palpate the brachial pulse. D) Auscultate the apical pulse.

C) Palpate the brachial pulse.

A nurse is reviewing the laboratory test results of an adult client who has numerous chronic health challenges. Which assessment result would alert the nurse to potential malnutrition? A) Hemoglobin of 13.1 g/dL B) Hematocrit of 40% C) Serum albumin of 2.6 g/dL D) Total protein of 7 g/dL

C) Serum albumin of 2.6 g/dL

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? A) Legs B) External genitalia C) Upper abdomen D) Buttocks

C) Upper abdomen

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? A) Document absence of dorsalis pedis pulse. B) Auscultate the anatomic area with a stethoscope. C) Use Doppler ultrasonography to locate the pulse. D) Apply a tourniquet for 2 minutes and then reassess.

C) Use Doppler ultrasonography to locate the pulse.

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? A) Sedentary lifestyle B) A family history of arterial insufficiency C) Intake of 1 to 2 alcoholic drinks per day D) 14-year history of smoking a pack a day

D) 14-year history of smoking a pack a day

An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following? A) 12 B) 18 C) 25 D) 28

D) 28

The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate? A) At the anterior area of the sternoclavicular joint B) At the posterior temporomandibular joint C) At the olecranon process of the elbow D) At the back of the wrist and extended thumb

D) At the back of the wrist and extended thumb

The nurse is assessing an adolescent client and notes 45-degree flexion of the cervical spine. What is the nurse's most appropriate action? A) Facilitate a referral for medical follow up. B) Palpate the spinous processes. C) Perform the Lasegue test. D) Continue the exam because this curve is normal.

D) Continue the exam because this curve is normal.

A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess? A) Joint dislocation B) History of fracture C) History of dental abscess D) Difficulty chewing

D) Difficulty chewing

A nurse asks a client to bring his hands together behind his head with his elbows flexed. The nurse is testing which of the following? A) Abduction B) Adduction C) Internal rotation D) External rotation

D) External rotation

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? A) Temporal B) Brachial C) Popliteal D) Femoral

D) Femoral

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following conclusions is suggested if the client has no reaction? A) It indicates high cholesterol and triglyceride levels. B) It shows a sacrifice of skeletal muscle proteins and blood proteins. C) It is indicative of unhealthy dietary habits. D) It may be immunosuppression resulting from undernourishment.

D) It may be immunosuppression resulting from undernourishment.

The nurse is collecting data from a client about his nutrition. Which of the following would the nurse document as objective data? A) Client states he is not eating well. B) Client complains of nausea and vomiting. C) Clients experiences urinary frequency. D) Tenting of client's skin observed upon skin pinch.

D) Tenting of client's skin observed upon skin pinch.

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? A) The client takes medications to treat hypertension. B) The client suffered a fractured humerus 1 year earlier. C) The client has a diagnosis of type 1 diabetes. D) The client had a total hip replacement 2 years ago.

D) The client had a total hip replacement 2 years ago.

The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following? A) The client's leg length B) The client's lateral bending ability C) The client's cervical ROM D) The client's gait

D) The client's gait

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? A) Blood is returning from the client's toe more slowly than normal. B) There is a blockage or infection in the client's lymphatic system. C) There is a disruption in osmotic pressure in the client's extremities. D) The client's toe is receiving an inadequate supply of blood.

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

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) Posterior neck B) Axillary area C) Inguinal area D) Upper arm

D) Upper arm

A nurse is providing care to an aging adult with a history of heart failure and peripheral vascular unable to stand or ambulate. The nurse should implement measures to prevent what complications:

Deep vein thrombosis

The nurse is providing care to a client with a venous ulcer on the leg. Based on the nurses understanding of the peripheral vascular system, how should the nurse best position the client:

Elevate the clients lower extremities

The nurse is performing an assessment on a young adult. The nurse is unable to palpate the pulse...Next action by the nurse would be to

Have the patient sit and recheck pluses in 30 mins

The nurse is performing an assessment on a pregnant client. The nurse observes bilaterally pitting edema... bilaterally. The next action by the nurse is to:

Obtain a STAT blood pressure and notify the physician immediately (heart failure)

The nurse performs an Allen test on a client. The test is used to determine if an occlusion is present.

Radial

The nurse is performing a peripheral vascular assessment on a bedridden client. The following findings are documented, "right leg with increased warmth, swelling, redness, tenderness to palpation, and a positive Homan's sign" Which action should the nurse take based on the assessment findings?

Seek emergency referral due to the risk of pulmonary embolism

The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response?

Teach the patient that circulatory changes during pregnancy frequently cause varicose veins; Assess the client ankle- brachial index (ABI) and perform doppler ultrasound testing

A nurse is caring for a client who is a smoker with a two year history using oral contraceptives. Based on the findings the client should be assessed for which conditions:

Venous thromboembolism (dvt)

The nurse is caring for several clients. Which of the following clients is the highest risk for development of venous disease?

a person who has been on bed rest for 4 days (immobility)

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

behind the ankle

The nurse is providing care to a client with venous insufficiency. A skin ulcer associated with venous insufficiency is most likely found on which area of the lower extremities:

calf of the leg

A client complains of swollen legs and feet. How can the nurse best initially assess the degree of edema in the lower extremities?

check for pitting

A 35 year old man is seen in the clinic for an "infection in my left foot" which of the following would the nurse expect to find during an assessment of this client?

enlarged and tender inguinal nodes

The nurse is caring for a client who is diagnosed with Raynaud's phenomenon. The nurse which nursing diagnosis:

ineffective tissue perfusion

A 67 year old client states that he recently began to develop pain in his left calf when climbing the 10 stairs to his apartment. This pain is reflected by sitting for about 2 minutes, then he is able to resume his activities. this client is most likely experiencing

intermittent claudication (cramping)

a client complains of a leg pain that wakes him at night. he states that he "has been having problems" with his legs. he has pain his legs when they are elevated, which disappears when he dangles them and has "a sore" on the inner aspect of the right ankle. on the basis of this history information, the client is most likely experiencing:

problems related to arterial insufficiency

In assessing the client with arterial insufficiency, the nurse correlates which finding with this disorder?

skin that appears thin, shiny, and taut over the lower legs