HESI peripheral vascular and lymphatics

What follow-up question by the nurse provides the best information about the client's claudication distance?

"How far do you walk before the leg cramps begin?" Claudication distance refers to the distance, such as blocks walked, or stairs climbed, that produces pain.

Which question that the client ask the nurse, indicate that more teaching needs to be done?

"Will I receive a diuretic for the swelling?" This answer requires more teaching because diuretics should not be used to help lymphedema. They draw off water in the interstitial spaces, and once the diuretic is out of the system, it will pull more water into the affected area.

The nurse has already observed that both of the clients' feet are cool and pale. What questions should the nurse ask the client to obtain additional supporting data?

"Do your toes or toenails ever look blue?" Cool skin temperature and pallor are signs of diminished arterial circulation. Cyanosis, a bluish color, of the tips of the toes or nail beds, is also an indicator of decreased arterial circulation. "Do you feel tingling, numbness, or burning sensations in your legs and feet?" Cool skin temperature, paresthesia, and pallor are signs of diminished arterial circulation. Cyanosis, a bluish color of the tips of the toes or of the nail beds is also an indicator of decreased arterial circulation.

To learn about any history of intermittent claudication, what question should the nurse ask?

"Have you experienced any leg cramping or pain in your legs?" Claudication is cramp-like calf pain, associated with diminished blood supply to the leg muscles. When this pain occurs only at specific times, such as during activities, it is referred to as intermittent claudication.

To palpate the epitrochlear node

-support clients hand with yours -with other hand reach behind the elbow and place finger pad in groove between biceps and triceps muscle above medial console of the humerus -feel for the node

A healthy adult has about how many lymph nodes

600-700

The nurse next palpates the axillary nodes. Using the pads of the fingers, the nurse moves over the node area in a circular motion. Two nodes are palpable and are easily movable. What action should the nurse take in response

Assess the nodes further for consistency and any palpable matting. If lymph nodes are palpable, the nurse should assess for mobility, size, shape, consistency, and whether the nodes are discrete or matted. These findings should then be documented in the assessment record. Ask the client if any there is any tenderness upon palpation of the nodes. If lymph nodes are palpable, the nurse should assess for tenderness. This finding should then be documented in the assessment record.

When reporting to the supervisor, the nurse tells the supervisor that the client's pressure sore developed because the client had a stone in her shoe that she couldn't feel. How should the nurse summarize this initial report by the client?

Bilateral paresthesia in the feet. Paresthesia refers to abnormal sensation, such as numbness or tingling, so this is the best terminology to describe the client's report of numbness and lack of feeling in her feet.

What equipment should the nurse obtain prior to completing ankle Brachial index

Blood pressure cuff. A blood pressure cuff along with a Doppler probe is used to obtain the systolic blood pressure in the lower extremity. To calculate the ankle brachial index (ABI), this value is compared with the systolic blood pressure in the upper extremity.

What is the best way for the client to identify the affected or at risk extremity?

Carry a wallet card or ID bracelet that identifies the affected extremity. This is the most effective way to remind healthcare professionals to avoid venipunctures, blood pressures, and fingersticks on the affected extremity.

Although there is no visible swelling, the client's legs are large, so the nurse gently depresses the tissue over the tibia for one second, noting that the tissue bounces back immediately. What action should the nurse take next?

Compress the tissue more firmly for 5 seconds. To effectively assess for pitting edema, the RN should firmly depress the tissue for 5 seconds, release, and measure any resultant indentation.

Which approach is best for the nurse to use when assessing for capillary refill?

Depress the client's nailbed. To assess capillary refill, the RN first compresses the nailbed for 3 seconds. This results in blanching of the nailbed. The RN then measures the amount of time necessary for return of normal color of the nailbeds: the capillary refill time.

The client returns to the clinic in 1 week and reports that her arm seems to be more swollen and inflamed. To validate this subjective report, the nurse assesses for edema in the client's arm, noting that 2+ pitting edema is present. During her previous visit, the edema in the client's arm was recorded as 1+. What action should the nurse implement

Confirm that the clients' arm is more swollen than previously. Pitting edema of 1+ indicates mild pitting, or pitting of 2 mm.Pitting edema of 2+ indicates moderate edema, or pitting of 4 mm. This finding reflects that Lourdes' arm is more swollen than during the previous assessment.

The nurse observes that the wound bed is red and the tissue immediately surrounding the wound is inflamed. The nurse plans to document the stage of the wound.What additional action should the nurse take to correctly stage the wound?

Determine the depth of the wound and underlying tissue damage. Pressure ulcers are staged based on the depth of tissue damage to the dermis and underlying tissues, which may include underlying tendons, joint capsules, bones, and muscles.

To palpate the epitrochlear node, the nurse palpates the area above and behind the medial condyle of the humerus but is unable to palpate the node. What action should the nurse take next

Document that the node is not palpable. The epitrochlear lymph node is located in the groove between the biceps and triceps muscles, above the medial epicondyle of the humerus and is not normally palpable.

Doppler picks up regular swooshing sound in the dorsalis pedis pulse site What action should the nurse take?

Document the presence of the pulse heard by Doppler ultrasound. A regular swooshing sound indicates that a pulse is heard with the Doppler ultrasound stethoscope. This finding should be documented.

The nurse asks the client to stand and assesses for the presence of varicose veins. A large, dilated, torturous vein is observed, so the nurse checks for valve competence by placing one hand at the lower end of the vein, and then compressing the vein with the other hand 20 cm higher. While the client is standing, the nurse notes the absence of any dependent rubor. What action should the nurse take in response

Document this finding on the physical assessment form. Dependent rubor, a deep blue-red color when the legs are in a dependent position, occurs with severe arterial insufficiency. The absence of dependent rubor is a normal assessment finding, and should be documented in the physical assessment but requires no further intervention.

Which nursing diagnoses are a priority when developing the client's plan of care?

Impaired physical mobility. Lymphedema can make mobility difficult, especially lower extremity lymphedema. It is important to assess the client and refer to physical therapy for exercises and activity restrictions. Disturbed body image. A client with lymphedema may have a disturbed body image from such things as wearing over-sized clothes or two different sized shoes. It is important to address these things with the client. Risk for infection. Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Risk for impaired skin integrity. Skin on the affected arm may be more dry than normal. Good skin care is essential to prevent infection; wraps and compression stockings may retain moisture against the skin.

Which instruction is most important for the nurse to give a client who has lymphedema, when teaching about the importance of the lymphatic system?

It plays a major role in the body's defense against diseases. The 2 major functions of lymph nodes are (1) filtration of foreign material brought to the site and (2) circulation of lymphocytes. Lymphocytes, such as T, B and NK cells help prevent disease.

The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the presence of any undermining tracts, what action should the nurse implement?

Insert a sterile, cotton-tipped applicator to measure the depth. A sterile, cotton-tipped applicator can be gently inserted to measure the depth of the wound and any undermining tracts.

A complete arterial circulation assessment includes a Modified Allen's Test. Which approach is best for the nurse to use to conduct this test?

Instruct the client to make a fist several times for about 30 seconds. Making a fist several times causes the hand to blanch during the Modified Allen's Test. Obliterate the ulnar and radial pulses. The ulnar and radial arteries are obliterated by holding pressure for a few seconds until pallor in the hand occurs. Document that the test results show inadequate circulation to the hand if pinkness fails to return within 6 seconds. A blanched hand or pallor in the fingernails greater than 6 seconds after releasing ulnar pressure indicates inadequate circulation.

After assessing the femoral artery, the nurse palpates the inguinal lymph nodes. What technique should be used?

Move the finger pads over the area using a gentle circular motion. This technique allows effective palpation of the lymph nodes.

During the health history, the client reported that her feet and ankles swell occasionally. To assess for edema, what action the nurse take first?

Observe and compare the client's lower extremities. The RN should first assess for edema by observing a client's legs for any obvious swelling and by comparing the two extremities for differences in size.

During her initial clinic visit, the client radial pulse volumes were recorded as 3+ bilaterally. Assessment by the nurse finds that the left radial pulse volume is now 1+ and the right radial pulse volume is 3+. What additional assessment is important

Observe the appearance of the left hand. A 1+ pulse volume indicates diminished circulation, so further assessment of the left hand is a priority. The RN should assess the color, warmth, and capillary refill.

How should Cilostazole be taken?

One hour before, or two hours after a meal. The medication is most effective if taken on an empty stomach.

Both pulses are weak and thready What additional assessment information will validate this finding

Pale, cool skin Weak, thready pulses indicate diminished arterial circulation. Pale, cool skin is also likely to be present when arterial circulation is diminished, validating the finding of weak, thready pulses.

The nurse reviews the client's initial complaint that her feet feel numb with assessment should the nurse perform first

Palpate the dorsalis pedis pulse -measure arterial circulation -acute absence of arterial circulation would require immediate intervention

The nurse palpates the femoral artery and notes that it is weak. The nurse decides to assess for the presence of a bruit. What action should the nurse take

Position a stethoscope over the artery. A bruit is a swooshing sound heard when blood flow through an artery is turbulent. It is heard by placing a stethoscope over the artery.

It is most important to report which finding to the supervisor?

Stage 2 pressure ulcer. A stage 2 pressure ulcer in a client with diminished sensation and circulation requires intervention and should be immediately reported to the supervisor. Bilateral cyanosis in both legs. Bilateral cyanosis with diminished sensation and circulation requires intervention and should be immediately reported to the supervisor.

Which is the best answer the nurse can give in response to how the lymphatic system works?

The lymph system carries the lymphocytes throughout the body. They respond to foreign and abnormal substances, and communicate responses to other parts of the body.

Capillary refill under 2 seconds is

normal

An ABI value of .90 (90%) or less indicates the presence of.

peripheral vascular disease