Health Assessment Ch. 22

Oral contraceptive (Rationale: The use of oral contraceptives increases a client's risk for thrombophlebitis, necessitating a thorough assessment. Antihypertensives help control hypertension and antilipids help reduce elevated cholesterol levels, which if not treated properly could damage blood vessels. Antidepressants may help a client reduce stress, which can increase the heart rate and blood pressure and contribute to vascular disease)

A 42-year-old woman reveals an intake of medications. Which medication if reported by the client would alert the nurse to the need to assess the client for thrombophlebitis?

It filters harmful substances from the body. (Rationale: The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system.)

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?

Upper abdomen (Rationale: The superficial inguinal nodes drain the legs, external genitalia, lower abdomen, and buttocks.)

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?

Document this finding as normal. (Rationale: A capillary refill of less than 2 seconds is a normal finding and would be documented as such. The pulse would not need to be rechecked or reassessed. No referral would be necessary.)

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

Examine the lower arm and hand for infection sites. (Rationale: Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm. Therefore, the nurse should examine those areas for possible infection. Ear or throat infections would not affect the epitrochlear nodes. Assessing the cervical lymph nodes might be appropriate if the client had generalized lymphadenopathy. Assessing the bilateral dorsalis pedis pulses would be performed for a concern involving the lower extremities.)

A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. What will the nurse do next?

1.1 (Rationale: An ankle-brachial index between 1.0 and 1.2 is considered normal, indicating that there is no arterial insufficiency. An index between 0.8 and 1.0 suggest mild insufficiency. An index between 0.5 and 0.8 indicates moderate insufficiency.)

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

Listen for femoral bruits (Rationale: Difficulty in palpating the femoral pulse could suggest arterial occlusion. Therefore the nurse should auscultate the femoral artery for bruits. Bruits over one or both femoral arteries suggest partial obstruction of the vessel and diminished blood flow to the lower extremity. Asking another nurse to assess the pulse may be appropriate but it would not provide as much information as auscultation would. If the femoral pulse is difficult to palpate, an occlusion may be present, making assessment of the popliteal pulse also difficult. The Allen test is done to evaluate the radial or ulnar arteries in the arm. The problem area here is the lower extremity.)

A nurse is having difficulty palpating the femoral pulse on an adult client. Which of the following would be most appropriate for the nurse to do?

Upper arm (Rationale: The epitrochlear nodes are located approximately 3 cm above the elbow on the inner aspect of the arm. The posterior cervical and occipital nodes would be palpated on the posterior aspect of the neck. The axillary lymph nodes would be palpated in the axillary area.)

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

Palpate the brachial pulse. (When unable to palpate a peripheral pulse, the pulse area immediately proximal to it should be palpated. In this case, the brachial pulse is indicated. Inability to palpate the client's pulses suggests arterial insufficiency. The nurse should not abandon this component of assessment. Referral is not always necessary, and further data are needed.)

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

0.50 (Rationale: To obtain the ankle-brachial index, the nurse would divide the higher ankle pressure for each foot by the higher brachial pressure. In this case, the right ankle-brachial index would be 80 divided by 160, which would equal 0.50. The left ankle-brachial index would be 94 divided by 160, which would equal 0.59.)

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

Varicose veins (Rationale: The manual compression test is done to evaluate the competence of the veins' valves in clients with varicose veins. It is not used to assess venous ulcers, arterial occlusion, or lymphedema.)

A nurse prepares to perform the manual compression test on a client with which of the following?

Student compresses the client's nail bed until it blanches. (Rationale: Capillary refill is assessed by compressing the nail bed until it blanches and then releasing the pressure, noting the time it takes for the color to return. Gentle compression of the wrist area on the thumb side is appropriate when taking a radial pulse. Applying firm pressure to note indentation tests for pitting edema. Having the client turn his or her hands over and back allows for inspection of hand color)

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

Arterial insufficiency (Rationale: Cool, pale skin, delayed capillary refill, and absence of pulses are associated with arterial insufficiency. Pain, muscle cramping, and weakness with activity may indicate arterial disease. Musculoskeletal weakness would be associated with complaints of fatigue or a decrease in strength. With venous insufficiency, edema would most likely be noted. Neurologic impairment would include possible complaints of numbness, tingling, or changes in sensation.)

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?

Compare measurements of both extremities. (Rationale: If the legs appear asymmetric, the nurse should measure each leg and then compare the measurements to confirm the difference. The Allen test is used to evaluate the patency of the radial or ulnar arteries. Checking for varicosities and palpating the femoral pulses are routine parts of the exam and unrelated to the assessment findings.)

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. What would the nurse do next?

"Arteries have thicker walls than veins." (Rationale: Arteries are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system. Arterial walls are thick and strong and contain elastic fibers for stretching. Veins contain nearly 70% of the body's blood volume.)

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

Arterial insufficiency (Rationale: An ABI lower than 0.9 indicates an increased chance of narrowed arteries (arterial insufficiency) and an increased risk of heart attack or stroke. ABI is not used to detect the presence of Raynaud disease, hypertension, or scleroderma.)

The nurse determine's that a client's ankle-brachial index (ABI) is 0.6. For which condition should the nurse anticipate treatment?

Unilateral edema (Rationale: Edema associated with lymphedema is usually nonpitting, unilateral, and without any skin ulceration or pigmentation. Edema associated with chronic venous insufficiency is usually pitting, and with skin ulceration and pigmentation.)

The nurse determines that a client's edema of the lower extremities is most likely due to lymphedema based on which of the following?

Document the finding and proceed with the assessment. (Rationale: It is not unusual for the popliteal pulse to be difficult or impossible to detect and yet for circulation to be normal. Consequently, referral is not necessary on the basis of this finding alone. Physical activity will not facilitate palpation. The brachial pulse is an important part of a vascular assessment, but is not directly related to the presence or absence of a palpable popliteal pulse.)

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 would the nurse do next?

Have the client stand for the exam. (Rationale: When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is not part of this assessment. The ankle-brachial index is used if the client has symptoms of arterial occlusion.)

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

Dry, shiny, hairless shins and feet (Rationale: Arterial insufficiency often results in dry, shiny, hairless skin on the lower extremities. Edema and reddish-blue coloration are characteristic of venous insufficiency. Arterial insufficiency does not normally result in numbness and tingling.)

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?

Hair loss on the legs may be an age-related change rather than a sign of arterial insufficiency. (Rationale: Hair loss on the lower extremities occurs with aging and is, therefore, not an absolute sign of arterial insufficiency in the older adult. Leg pain and absent peripheral pulses are considered pathologic in clients of all ages. There are characteristic differences in venous and arterial ulcers in all clients, regardless of age)

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. Have the client rest in a supine position for at least 5 minutes. B. Apply the blood pressure cuff to first one arm and then the other to determine the brachial pressure using the Doppler device. C. Apply the blood pressure cuff to the right ankle, then palpate the posterial tibial pulse at the medial aspect of the ankle and the dorsalis pedis pulse on the dorsal aspect of the foot. D. Using the Doppler device, determine the systolic pressure of the posterior tibial pulse and the dorsalis pedis pulse, and record both readings. E. Repeat the process on the opposing extremity. (Rationale: To measure the client's ABI, the nurse will have the client rest in a supine position for at least 5 minutes, apply the blood pressure (BP) cuff to first one arm and then the other to determine the brachial pressure using the Doppler. Then, the nurse will palpate the pulse and use the Doppler to hear the pulse. The "whoosh

The nurse is measuring the ankle-brachial index (ABI) for a client with suspected arterial occlusion. How will the nurse proceed with the assessment? Place the following tasks in the order the nurse will perform them.

Femoral (Rationale: The femoral pulse is palpated in the groin (inguinal area) by compressing the femoral artery between skin and bone. The temporal pulse is located on the head. The brachial pulse is palpated medial to the biceps tendon in and above the bend in the elbow. The popliteal pulse is palpated behind the knee.)

The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse?

Ulnar (Rationale: In some otherwise healthy clients, the ulnar pulses are not detectable. The radial, brachial, and femoral pulses should always be palpable, and absence of any is a pathologic finding)

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that what pulse may not be palpable, even in healthy clients?

Document the lack of patency in the ulnar and/or radial arteries.. (The Allen test evaluates patency of the radial or ulnar arteries. It does not address peripheral pulses in the lower extremities.)

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?

Behind the ankle Rationale: The posterior tibial pulse is palpated behind the medial malleolus of the ankle. The popliteal pulse is palpated just behind the knee. The dorsalis pedis pulse is palpated on the top of the foot along the great toe side. The femoral pulse is palpated in the groin area, just under the inguinal ligament.

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

A. Thrombophlebitis B. Raynaud disease C. Hypertension D. Edema (Rationale: The use of oral contraceptives while smoking increases a client's risk for thrombophlebitis, Raynaud disease, hypertension, and edema. Smoking and the use of oral contraceptives is not known to increase the risk of scleroderma.)

The nurse is teaching a 39-year-old female client about the risks of smoking while using oral contraceptives. Which condition(s) will the nurse review during the teaching? Select all that apply.

Use Doppler ultrasonography to locate the pulse. (Rationale: A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable. The nurse would need to attempt to assess the pulse, and if the pulse could not be obtained via Doppler, then it would be appropriate to document the absence of the pulse and include attempts to assess it, such as via palpation and Doppler ultrasound. Asking another nurse to assess the pulse would be helpful in confirming the finding, especially if no pulse was obtained via Doppler. Auscultating with a stethoscope would not be helpful.)

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?

Hold the probe at a 60- to 90-degree angle to the client's skin. (Rationale: At a 60- to 90-degree angle, the nurse should lightly place the vascular probe at the top of the mound of gel. Petroleum gel is not used for transmitting ultrasound waves. Pushing firmly with the probe may obliterate blood flow. To promote circulation, the client's skin should be warm.)

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?

The nurse should implement interventions to address severe arterial insufficiency. (Rationale: The ABI gauges the sufficiency of arterial blood flow. It does not directly evaluate venous return or the consequences of insufficient venous return, such as ulcers and edema.)

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?

Venous insufficiency (Rationale: Brown discoloration around the ankles occurs with chronic venous stasis resulting from hemosiderin deposits, which are byproducts of red blood cell degradation or iron deposits left behind from the process. There is no evidence of ulceration. Arterial occlusion would be associated with weak or absent pulses. Dependent edema is edema that results from the legs being in a dependent or down position. A brown pigmentation would not be present with dependent edema.)

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Venous insufficiency (Rationale: A rusty or brownish pigmentation around the ankles indicates venous insufficiency. This assessment finding is not suggestive of Raynaud's, CAD, or edema.)

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?

The client's toe is receiving an inadequate supply of blood. (Rationale: Arterial ulcers are frequently circular, painful, and deep. Venous ulcers, in contrast, are typically superficial with an irregular border. Disruptions in lymphatic function or osmosis would not result in a wound of this type.)

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 legs are visibly pale when elevated above the examination table. (Rationale: Marked pallor with legs elevated during the position change test is an indication of arterial insufficiency. A return to pink color should take place in less than 10 seconds. The position change test does not assess for signs of venous insufficiency such as edema. Pain is not assessed during the position change test.)

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?

14-year history of smoking a pack a day (Rationale: The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and amount of tobacco smoked. Factors such as lack of exercise, family history, and alcohol intake may be relevant, but smoking is the most significant risk factor.)

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?

Hydrostatic force (Rationale: For oxygen, water, and nutrients in the interstitial fluid to be delivered, hydrostatic force is the primary mechanism involved in allowing interstitial fluid to diffuse out of the capillaries and enter the tissue space. The fluid reenters the capillaries via osmotic pressure. Gravitational flow and diastolic pressure are unrelated to fluid exchange.)

When describing fluid exchange and the capillaries, the instructor explains which mechanism as the most likely cause if oxygen, water, and nutrients are having difficulty entering the interstitial fluid?

Brachial artery (Rationale: The brachial artery is the major artery that supplies the arm. The femoral artery is the major artery that supplies the leg. The brachial artery divides near the elbow into the radial and ulnar arteries)

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?

Muscular contractions (Rationale: Muscular contraction aids in returning blood to the heart. Skeletal muscles contract with movement, and in effect squeeze blood toward the heart. Blood returning to the heart must overcome gravity. Pressure gradients allow the movement of fluids and nutrients between the vessels. Heart muscle contraction is responsible for moving blood out of the heart into circulation.)

When reviewing the adult circulation, the nurse understands that which mechanism primarily aids in returning blood to the heart?

Have you experienced a change in your usual sexual activity? (Rationale: Impotence may occur in clients with decreased blood flow or occlusion of the blood vessels. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage to the blood vessels. It would not be important to ask the client about his last prostate exam. Asking about an electrocardiogram might be important if the client has risk factors for or has heart disease.)

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

Deep Circular in shape Client report of severe pain (Rationale: An ulcer due to arterial insufficiency typically is very painful, circular, and deep, often involving the joint space, with minimal leg edema. An ulcer due to venous insufficiency is usually superficial, with irregular borders, minimally painful unless deep, with moderate to severe leg edema.)

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