PrepU Chapter 18 Questions

A client presents with pitting edema to the left foot, which a nurse observes as slight pitting when the area is depressed. How should the nurse accurately document this amount of edema? a) 3+ b) 2+ c) 1+ d) 4+

1+ Explanation: Pitting edema that produces a noticeably deep pit when the area is depressed and where the extremity looks larger than the other is documented as 3+. A 1+ pitting edema is edema that produces slight pitting when the area is depressed. A 2+ is deeper than 1+. A 4+ pitting edema is a very deep pit in the area when depressed, and there is gross edema in the extremity.

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) 1.4 b) 0.5 c) 1.1 d) 0.8

1.1 Explanation: 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. ABI does not normally exceed 1.2.

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) A family history of arterial insufficiency b) 14-year history of smoking a pack a day c) Intake of 1 to 2 alcoholic drinks per day d) Sedentary lifestyle

14-year history of smoking a pack a day Explanation: 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.

The nurse is assessing a client with diabetes for peripheral artery disease. How does diabetes affect this client's risk of peripheral artery disease? a) No affect b) Significant affect c) 2 times d) 3 times

2 times Explanation: Diabetes significantly affects a client's risk of lower-extremity peripheral artery disease. Severity and duration of diabetes correlate with the likelihood of developing lower-extremity peripheral artery disease. No affect, 2 times, and are all incorrect statistics

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) 4+ b) 1+ c) 3+ d) 2+

4+ Explanation: A bounding pulse, one that is strong and does not disappear with moderate pressure, is recorded as 4+. An absent pulse is recorded as 0. A pulse that is thready is recorded as 1+; one that is weak is recorded as 2+; a normal pulse is recorded as 3+.

A nurse palpates the presence of an enlarged inguinal 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) Lower arm and hand for erythema and swelling c) Abdomen, noting any organ enlargement or tenderness d) Cervical lymph nodes for tenderness and swelling

Abdomen, noting any organ enlargement or tenderness Explanation: Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area. The epitrochlear nodes are located in the upper inside of the arm. Enlargement of these nodes may indicate infection in the hand or forearm or they may occur with generalized lymphadenopathy. Cervical lymph nodes are part of the system that drains the head and neck, and enlargement would be due to a recent ear infection, sore throat, or other upper respiratory tract infection.

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

A painless wound on the sole of the client's foot, which is surrounded by calloused skin Explanation: Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.

A 77-year-old retired nurse has an ulcer on a lower extremity. All the following diseases are responsible for causing ulcers in the lower extremities except for: a) Hypertension b) Venous insufficiency c) Diminished sensation in pressure points d) Arterial insufficiency

Hypertension Explanation: Hypertension is not directly associated with the formation of ulcers. It is an indirect risk factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to arterial insufficiency or neuropathy.

The nurse is preparing discharge teaching for a patient diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include? a) How to apply a nonelastic hose b) To walk at least 2 miles/day c) Signs and symptoms of DVT d) To avoid sitting for long periods

To avoid sitting for long periods Explanation: Patients with lymphatic disorders have several issues that you must address. As with venous disease, edema in the extremities is the primary symptom of lymphedema. Suggest that the patient avoid sitting or standing for long periods.

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

True

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? a) Intake of 2 beers per week b) A family history of arterial insufficiency c) Participation in daily exercise d) Cigarette smoking

You selected: Cigarette smoking Explanation: 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. Daily exercise would be a measure to reduce a person's risk for vascular disease. 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. Alcohol intake is unrelated to the development of chronic arterial insufficiency.

The nurse reads the previous shift's assessment documentation and notes local swelling, redness, and warmth. The oncoming nurse palpates a subcutaneous cord and suspects a) deep vein thrombosis b) a superficial thrombophlebitis c) femoral aneurysm d) venous insufficiency

a superficial thrombophlebitis Explanation: Superficial vein thrombophlebitis is marked by redness, thickening, and tenderness along the vein. Aching or cramping may occur with walking. Swelling and inflammation are often noted

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? a) lumbar node b) superficial inguinal node c) superficial popliteal node d) right cervical node

right cervical node Explanation: The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct

Patients with PAD need to understand why it is important to monitor a) Na+ and K+ levels b) blood urea nitrogen levels c) creatinine levels d) triglyceride levels

triglyceride levels Explanation: Monitoring and management of cholesterol and triglyceride levels is important for patients with PAD. They should have a thorough understanding of the relationship that diet, activity, and genetic factors have to cholesterol levels and the development of atherosclerosis.

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion? a) Allen test b) Valve competency c) Ankle brachial index d) Capillary refill

Allen test Explanation: Prior to the cannulation of the radial artery, an Allen test should be performed to assess the patency of collateral circulation. The ankle brachial index is performed on clients with peripheral arterial disease. Valve competency is not tested prior to insertion.

What is a long-term complication of peripheral vascular disease? a) Diabetes mellitus b) Thickened skin c) Amputation d) Metabolic changes

Amputation Explanation: Diseases of the peripheral vascular system, peripheral arterial disease, venous stasis, and thromboembolic disorders can severely affect the lifestyle and quality of life of patients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation.

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition? a) Venogram b) Ankle-brachial index (ABI) c) PET scan d) CT scan of the lower legs

Ankle-brachial index (ABI) Explanation: The ABI is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Approximately 16% of clients with known peripheral vascular disease also have coronary artery disease

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

Anxiety Explanation: Palpate the temperature of both legs and feet simultaneously with the backs of your hands. Compare the temperature of the legs. Bilateral coolness is most often caused by a cold environment or anxiety.

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? a) Musculoskeletal weakness b) Neurologic impairment c) Arterial insufficiency d) Venous insufficiency

Arterial insufficiency Explanation: 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.

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what? a) Deep vein thrombosis b) Venous thromboembolism c) Arterial occlusion d) Pulmonary embolism

Arterial occlusion Explanation: Symptoms of a complete arterial occlusion includes pain, numbness, coolness, or color change of an extremity and is an emergency. A deep vein thrombosis is characterized by pain, edema and warmth of the extremity. Pulmonary embolism symptoms include acute dypsnea, chest pain, diaphoresis and anxiety. Venous thromboembolism occurs when a blood clot travels from the legs to the lungs.

During a health visit, a client says, "I know that arteries and veins are both blood vessels, but what's 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 carry waste from the tissues. d) Arteries have a lower pressure than veins.

Arteries have thicker walls than veins. Explanation: 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.

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

Assess adequacy of blood flow using a Doppler device. Explanation: Arterial insufficiency causes a decrease in the amount of blood flow to an extremity. If the blood flow is diminished significantly, the adequacy of the pulse may also diminish. Therefore, if a pulse cannot be palpated, the nurse's best action is to obtain a Doppler device to assess for adequate blood flow. A Doppler device works by transmitting ultra-high-frequency sound waves in a way that they strike red blood cells in an artery or vein. This rebounding ultrasound waves produces a whooshing sound that is transmitted through the Doppler. Attempting to palpate the posterior tibial pulse does not provide information about the dorsalis pedis pulse. Checking the extremity for findings of decreased blood flow is not necessary because the nurse is already aware that the client has arterial insufficiency and needs to determine the extent, not the presence, of the disease. The ankle brachial index is a much more complex test that can be performed after the Doppler determines whether or not a pulse is present.

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

Assist the client to walk as soon and as often as possible. Explanation: Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a client who has one normal beat followed by a premature contraction in conjunction with premature ventricular contractions? a) Bisferiens pulse b) Bigeminal pulse c) Pulsus alternans d) Paradoxical pulse

Bigeminal pulse Explanation: Bigeminal pulse has one normal beat followed by a premature contraction and is seen in premature ventricular contractions. The nurse would find pulsus alternans in the client with left ventricular failure. Pulsus alternans is characterized by changes in amplitude from beat to beat and is usually seen in left ventricular failure. Paradoxical pulse is a decrease in pulse amplitude on quiet inspiration and is seen in pericardial tamponade, constrictive pericarditis, and obstructive lung disease. Bisferiens pulse has a double systolic peak and is seen in aortic regurgitation, combined aortic stenosis, and regurgitation.

The nurse is assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities. In which of the following locations would the client's pain be most concerning? a) Thigh b) Knee c) Ankle d) Calf

Calf Explanation: Pain in the calf is the most common site for claudication; however, there could be pain in the buttock, hip, thigh, or foot depending on the level of the obstruction. Absence of this pain does not rule out significant vascular disease—actually, the minority of these clients are symptomatic.

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

Check feet daily for cuts or pressure areas. Explanation: Because of decreased blood flow, the client needs to check feet daily for cuts or pressure areas so that treatment to prevent arterial ulcers can begin immediately. Compression stockings should not be worn by clients with peripheral arterial disease. Disfigurement is not common in clients with peripheral arterial disease. There will be decreased hair and the skin will be shiny in clients with peripheral arterial disease.

Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next? a) Perform the Allen's test b) Check for bilateral varicosities. c) Compare measurements of both extremities. d) Palpate the femoral pulses.

Compare measurements of both extremities. Explanation: If the legs appear asymmetric, the nurse should measure each leg and then compare the measurements to confirm the difference. The Allen's 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.

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) Cool foot temperature and ulceration on the client's great toe c) Thickened and scarred skin on the client's ankle d) Brown pigmentation around a client's ankles and shins

Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease? a) Diabetes b) Lymphedema c) Peripheral arterial disease d) Venous disease

Diabetes Explanation: Clients with decreased or no pain sensation should be asked about a history of diabetes as it may be related to diabetic neuropathy. Peripheral arterial diease is characterized by pain. Venous disease is accompanied by heaviness and an aching sensation. Lymphedema is characterized by nonpitting edema.

A finding on palpation that suggests venous insufficiency is: a) Diminished sensations of dorsum of right foot b) Ulcerations on toes of left foot c) Diminished dorsalis pedis pulse in an edematous foot d) Cool lower legs and feet

Diminished dorsalis pedis pulse in an edematous foot Explanation: Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be on the sides of the foot and temperature is usually normal. Sensation does not tend to diminish.

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) Recheck in 5 minutes after elevating the arm. b) Refer the client for medical follow-up. c) Document this finding as normal. d) Reassess after applying warm compresses.

Document this finding as normal. Explanation: 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.

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) Numbness and tingling of the lower extremities c) Reddish-blue coloration of the shins and feet d) Pitting edema to the feet and ankles

Dry, shiny, hairless shins and feet Explanation: 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.

A nurse observes a decrease in hair on the lower extremities of an elderly client. What is an appropriate action by the nurse in regards to this finding? a) Check for ulcers on the medial aspect of the ankles. b) Ask the client about the presence of edema in the feet. c) Document this as a normal process of aging. d) Elevate the legs and observe for the onset of pallor.

Elevate the legs and observe for the onset of pallor. Explanation: Loss of hair can be a normal finding in the elderly client, but the nurse should perform further assessment before making this judgment. Loss of hair is seen with arterial insufficiency. Ulcers on the medial aspect of the ankle are a sign of venous stasis as is the presence of edema. Pallor, or loss of color, is seen in arterial insufficiency, especially when the legs are elevated

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action? a) Assess for diminished pulses. b) Elevate the legs on pillows. c) Observe for gangrene areas. d) Lower the legs below heart level.

Elevate the legs on pillows. Explanation: Common complaints of venous ulcer pain include: aching pain and feeling of heaviness which is relieved with elevation of the legs. Relief for arterial ulcer pain is achieved by dependently positioning the legs below the heart. Gangrene and decreased pulses more commonly occur with arterial ulcers; assessing for these symptoms doesn't address the client's pain

A nurse performs the Allen's test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test? a) Keep both arteries occluded and have the client release the fist. b) Ensure that the client's hand is not opened in exaggerated extension. c) Use the thumbs to occlude the radial and ulnar arteries. d) Have the client rest the hand palm side up and make a fist.

Ensure that the client's hand is not opened in exaggerated extension. Explanation: Opening the hand into exaggerated extension may cause persistent pallor, giving a false-positive test; hence, the nurse should ensure that the client's hand is not opened in exaggerated extension. To perform the test, the nurse is required to have the client rest the hand palm side up and make a fist, use the thumbs to occlude the radial and ulnar arteries, and keep both arteries occluded and have the client release the fist.

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) Feel for a pulsation to the fingers in the lower hand b) Place the second hand 3 to 4 inches above the first hand c) Ask the client to sit on a chair for the examination d) Firmly compress the lower portion of the varicose vein

Firmly compress the lower portion of the varicose vein Explanation: The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand.

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) Venous ulcers and arterial ulcers have a similar appearance and course in older adults. b) Non-palpable peripheral pulses are expected in clients over the age of 80. c) Leg pain that is relieved by rest is the result of normal physiological changes. d) Hair loss on the legs may be an age-related change rather than a sign of arterial insufficiency.

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

When assessing a client for possible varicose veins, which of the following would the nurse do? a) Dorsiflex the client's foot b) Have the client stand for the exam c) Tell the client to raise his or her leg d) Obtain the ankle-brachial index

Have the client stand for the exam Explanation: 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 used to assess the Homans' sign. The ankle-brachial index is used if the client has symptoms of arterial occlusion

A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding? a) History of Raynaud's disorder b) Presence of peripheral artery disease c) History of breast surgery d) Presence of deep vein thrombosis

History of breast surgery Explanation: Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Raynaud's disorder is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes and is typically bilateral. Peripheral artery disease involves reduced blood flow to the limbs and is characterized primarily by intermittent claudication, not by edema. Deep vein thrombosis is caused by obstruction of the veins and is not associated with lymphedema.

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

Intermittent claudication Explanation: Pain brought on by exertion and relieved by rest is called intermittent claudication. Varicose veins are due to incompetent valves. Signs of a pulmnary embolus include acute dyspnea, chest pain, tachycardia, diaphoresis, a anxiety. Deep vein thrombosis symptoms include pain, edema, and warmth of an extremity.

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? a) It manufactures T lymphocytes. b) It drains capillary blood from the circulation. c) It filters harmful substances from the body. d) It produces protective antibodies.

It filters harmful substances from the body. Explanation: 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 nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a) Have the client stand upright after tourniquet removal b) Ensure that the client's legs are over the side of the bed c) Legs should be elevated for 15 seconds d) Tourniquet should be put on before leg elevation

Legs should be elevated for 15 seconds Explanation: When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.

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) Lightly palpate the client's leg veins for tenderness b) Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe c) Have the client sit down d) Use a Doppler ultrasound device on the client's leg

Lightly palpate the client's leg veins for tenderness Explanation: To fully assess for a suspected phlebitis, lightly palpate for tenderness. The client should still be standing from the inspection of the legs. A Doppler ultrasound device is used to assess for pulses when they are difficult to palpate. Dorsiflexing the client's foot and applying light pressure along the extensor tendon of the big toe are done when palpating for the dorsalis pedis pulses.

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? a) Ask another nurse to assess the pulse. b) Listen for femoral bruits. c) Perform the Allen's test. d) Assess the popliteal pulse.

Listen for femoral bruits. Explanation: 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 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) Lower arm and hand for erythema and swelling d) Abdomen, noting any organ enlargement or tenderness

Lower arm and hand for erythema and swelling Explanation: The epitrochlear nodes are located in the upper inside of the arm. Enlargement of these nodes may indicate infection in the hand or forearm or they may occur with generalized lymphadenopathy. Cervical lymph nodes are part of the system that drains the head and neck, and enlargement would be due to a recent ear infection, sore throat, or other upper respiratory tract infection. Inflammation or infection in the abdomen would drain into the inguinal nodes located in the groin area.

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? a) Antihypertensive b) Antilipid agent c) Oral contraceptive d) Antidepressant

Oral contraceptive Explanation: 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 client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency? a) Reports of aching, cramping pain b) Irregular-shaped ulcer on the inner aspect of the ankle c) Ulcer located on medial malleolus d) Pallor of foot occurs with elevation

Pallor of foot occurs with elevation Explanation: The ulcers due to arterial insufficiency would have elevation pallor of the foot due to poor blood supply. Aching and cramping pain is present in ulcers caused by venous insufficiency. Irregular-shaped ulcers and ulcers located on the medial malleolus are characteristics of venous insufficiency ulcers.

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

Palpate the brachial pulse. Explanation: 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.

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

The client's toe is receiving an inadequate supply of blood. Explanation: 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 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 implement interventions to address severe arterial insufficiency. b) The nurse should assess the client's extremities for pitting edema at least once per shift. c) The nurse should inspect the client's feet and ankles for venous ulcers once per shift. d) The nurse should position the client to promote venous return.

The nurse should implement interventions to address severe arterial insufficiency. Explanation: 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.

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

Thoracic ducts Explanation: The thoracic ducts at the junctions of the subclavian and internal jugular veins return the lymph fluid to the circulation. There are no internal jugular, epitrochlear, or infraclavicular ducts.

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves? a) Ankle-brachial pressure index (ABPI) b) Trendelenburg test c) Position change test d) Allen test

Trendelenburg test Explanation: If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins. The ABPI is considered an accurate objective assessment for determining the degree of peripheral arterial disease. The position change test is done to further assess for arterial insufficiency in the legs following the determination of weak pulses. The Allen test evaluates patency of the radial or ulnar arteries. It is implemented when patency is questionable or before such procedures as a radial artery puncture.

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) Brachial b) Radial c) Ulnar d) Femoral

Ulnar Explanation: In some 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.

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) Upper abdomen b) Buttocks c) Legs d) External genitalia

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

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? a) Upper arm b) Inguinal area c) Posterior neck d) Axillary area

Upper arm Explanation: 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.

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) Auscultate the anatomic area with a stethoscope. b) Ask another nurse to assess the pulse. c) Document "absence of dorsalis pedis pulse." d) Use Doppler ultrasonography to locate the pulse.

Use Doppler ultrasonography to locate the pulse. Explanation: 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'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

Venous insufficiency Explanation: 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 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) Dependent edema b) Arterial occlusion c) Venous insufficiency d) Stasis ulceration

Venous insufficiency Explanation: 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? a) Arterial occlusion b) Dependent edema c) Stasis ulceration d) Venous insufficiency

Venous insufficiency Explanation: 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 notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely? a) Arterial insufficiency b) Trauma c) Neuropathic ulcer d) Venous insufficiency

Venous insufficiency Explanation: These features are most consistent with venous insufficiency. Other findings include scaling, redness, and varicosities. Arterial insufficiency usually affects distal or traumatized areas. Other clues of arterial insufficiency would most likely be present. Neuropathic ulcers occur because of decreased sensation, and are common in clients with neuropathy. They are often over bony prominences with surrounding calluses.

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what? a) Venous insufficiency b) Hypertrophic changes c) Arterial insufficiency d) Intermittent claudication

Venous insufficiency Explanation: Venous insufficiency is characterized by aching, cramping, pigment changes. If the client has an ulcer, it will be painful. Arterial insufficiency is characterized by decreased pulses, dry, shiny, cold skin. Intermittent claudication is pain brought on by exertion and relieved by rest. Hypertrophic changes include a loss of hair and pallor.

The largest arteries of the upper extremities are the a) brachial arteries b) abdominal arteries c) radial arteries d) subclavian arteries

brachial arteries Explanation: The largest arteries of the upper extremities are the brachial arteries.

The major artery that supplies blood to the arm is the a) brachial artery. b) ulnar artery. c) radial artery. d) posterior artery.

brachial artery. Explanation: The brachial artery is the major artery that supplies the arm.

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

brisk, expected (normal) pulse Explanation: A +2 pulse is a normal pulse.

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the a) competence of the saphenous vein valves. b) severity of thrombophlebitis. c) pulse of a client with poor elasticity. d) degree of arterial occlusion that exists.

competence of the saphenous vein valves. Explanation: If the client has varicose veins, perform the Trendelenburg test to determine the competence of the saphenous vein valves and the retrograde (backward) filling of the superficial veins.

The nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing a) varicose veins. b) thrombophlebitis. c) edema. d) intermittent claudication.

intermittent claudication. Explanation: Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity.

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for a) bruits over the radial artery. b) poor peripheral pulses. c) Raynaud disease. d) lymphedema.

lymphedema. Explanation: Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema.

A client's blood pressure amplitude is low during inspiration and higher during expiration. What should this finding suggest to the nurse? a) pulsus alternans b) arterial insufficiency c) paradoxical pulse d) superficial venous thrombosis

paradoxical pulse Explanation: Paradoxical pulse means the pulse beat amplitude is weaker during inspiration and stronger during expiration. This is due to a greater than normal drop in systolic blood pressure during inspiration. In pulsus alternans, the rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions. A marked difference in the color of an extremity with a change in position indicates arterial insufficiency. Superficial venous thrombosis is characterized by pain and tenderness in a local area along the course of a superficial vein, most often in the saphenous system.

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

popliteal Explanation: Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client? a) arterial insufficiency b) deep vein thrombosis c) atherosclerosis d) venous insufficiency

venous insufficiency Explanation: Brownish discoloration just above the malleolus suggests chronic venous insufficiency. There are no specific skin changes associated with atherosclerosis. The lower extremities in the dependent position would be pale in color in arterial insufficiency. The extremity would be warm and edematous with a deep vein thrombosis.

A client with hypertension is at increased risk of what medical conditions? Select all that apply. a) Cerebrovascular disease b) Deep vein thrombosis c) Varicose veins d) Lower-extremity peripheral artery disease e) Abdominal aneurysms

• Cerebrovascular disease • Lower-extremity peripheral artery disease • Abdominal aneurysms Explanation: Clients with hypertension are at increased risk for cardiovascular disease, especially cerebrovascular disease, lower-extremity peripheral artery disease, and abdominal aneurysms. People with hypertension have not been shown to be at greater risk for deep vein thrombosis or varicose veins

While completing the past history of a patient's peripheral vascular and lymphatic systems, the nurse is concerned that the patient is at risk for peripheral vascular disorders. What assessment data would cause the nurse to arrive at this conclusion? (Select all that apply.) a) Blood pressure 178/90 mm Hg b) Body mass index 30 c) Currently smokes one pack per day d) Mother diagnosed with diabetes at age 70 e) Heart attack 5 years ago

• Currently smokes one pack per day • Body mass index 30 Explanation: Risk factors for the development of peripheral vascular disease include smoking and obesity. The history of a heart attack and current blood pressure would be documented under the patient's past history. The mother being diagnosed with diabetes at the age of 70 would be documented under family history. Having had a heart attack, having hypertension, and a family history of diabetes are not considered risk factors for the development of peripheral vascular disease

The nurse is preparing to conduct a peripheral vascular and lymphatic physical examination of a patient's legs. What instructions should the nurse provide the patient in order to prepare for this examination? (Select all that apply.) a) Lay on your back on a bed or examination table. b) Be aware that the examination can be painful c) Be prepared to lay on your stomach for a portion of the examination. d) Refrain from talking during the examination e) Remove clothing below the waist.

• Remove clothing below the waist. • Lay on your back on a bed or examination table. • Be prepared to lay on your stomach for a portion of the examination. Explanation: To conduct a peripheral vascular and lymphatic physical examination of the legs, the patient will need to remove clothing below the waist, be in a lying position on a bed or examination table, and may need to move into the prone position to assess some pulses. The assessment of the peripheral vascular and lymphatic systems of the legs do not require silence nor is it typically a painful process

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply. a) Activity level b) Intraluminal valves c) Respiration d) Cardiac output e) Skeletal muscle contraction

• Skeletal muscle contraction • Respiration • Intraluminal valves Explanation: A pressure gradient created by respiration, skeletal muscle contraction, and intraluminal valves regulates blood flow in the venous system. It has not been shown that cardiac output or activity level affects this pressure gradient