Ch18 Peripheral Vascular System
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When performing an assessment on a client the nurse notes the presence of an enlarged epitrochlear lymph node. The nurse would anticipate finding which of the following on the assessment?
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The forearm and hand for infection or inflammation
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The lower legs for injury
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The equality of radial pulse
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Capillary refill and temperature of the extremities
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This quiz assesses nursing knowledge related to the peripheral vascular system, focusing on lymph node assessment, circulation checks, and identifying symptoms of common conditions. It is designed to enhance practical skills in diagnosing and managing vascular health issues.
- 2.
When performing an assessment on a client the nurse notes the presence of an enlarged superficial inguinal nodes. The nurse would anticipate finding which of the following on the assessment?
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The forearm and hand for infection or inflammation
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The lower legs for injury
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The equality of radial pulse
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Capillary refill and temperature of the extremities
Correct Answer
A. The lower legs for injuryExplanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.Rate this question:
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- 3.
When performing an assessment on a client the nurse notes the determine circulation. The nurse would anticipate finding which of the following on the assessment?
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The forearm and hand for infection or inflammation
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The lower legs for injury
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The equality of radial pulse
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Capillary refill and temperature of the extremities
Correct Answer
A. The equality of radial pulseExplanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.Rate this question:
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- 4.
When performing an assessment on a client the nurse notes the determine circulation to the extremities. The nurse would anticipate finding which of the following on the assessment?
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The forearm and hand for infection or inflammation
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The lower legs for injury
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The equality of radial pulse
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Capillary refill and temperature of the extremities
Correct Answer
A. Capillary refill and temperature of the extremitiesExplanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.Rate this question:
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- 5.
When performing an assessment, the nurse notes the presence of ankle edema bilaterally. The nurse knows that:
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It is caused by an infection.
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It is caused by blood pooling in the legs.
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It is caused by a blood clot in the lower leg.
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It is caused by decreased arterial circulation.
Correct Answer
A. It is caused by blood pooling in the legs.Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.Rate this question:
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- 6.
When performing an assessment, the nurse notes the presence of inflammation and edema over the affected area. The nurse knows that:
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It is caused by an infection.
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It is caused by blood pooling in the legs.
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It is caused by a blood clot in the lower leg.
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It is caused by decreased arterial circulation.
Correct Answer
A. It is caused by an infection.Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.Rate this question:
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- 7.
When performing an assessment, the nurse notes the presence of edema in the affected extremity. The nurse knows that:
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It is caused by an infection.
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It is caused by blood pooling in the legs.
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It is caused by a blood clot in the lower leg.
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It is caused by decreased arterial circulation.
Correct Answer
A. It is caused by a blood clot in the lower leg.Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.Rate this question:
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- 8.
When performing an assessment, the nurse notes the presence of decreased pulses. The nurse knows that:
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It is caused by an infection.
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It is caused by blood pooling in the legs.
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It is caused by a blood clot in the lower leg.
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It is caused by decreased arterial circulation.
Correct Answer
A. It is caused by decreased arterial circulation.Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.Rate this question:
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- 9.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Which of the following should the nurse do?
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Continue with the assessment as this is a normal neonatal blood pressure reading.
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Perform a focused assessment and call the health care provider.
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Assess the thigh blood pressure expecting that it will be lower than that of the arm.
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Ask another nurse to validate the blood pressure because it is low.
Correct Answer
A. Continue with the assessment as this is a normal neonatal blood pressure reading.Explanation
The systolic blood pressure of a newborn is 50 to 80 mm Hg; the diastolic blood pressure is 25 to 55 mm Hg. Since this is a normal finding, the nurse should continue with the assessment.
Calling the health care provider is not indicated with this normal finding.
In an infant less than one year of age, the systolic blood pressure in the thigh should equal that in the arm.
In a child over one year of age, the systolic pressure in the thigh is 10-40 mm Hg higher than that in the arm.
Another nurse does not need to validate the blood pressure since it is within normal limits.Rate this question:
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- 10.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. What can the nurse tell the client about these veins?
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"These are common and will go away after delivery."
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"We need to talk to your health care provider about this."
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"This is a normal finding and is caused by pressure from your uterus delaying blood return from your legs."
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"This is related to decreased circulation."
Correct Answer
A. "This is a normal finding and is caused by pressure from your uterus delaying blood return from your legs."Explanation
Pressure from the uterus on the lower extremities is common during pregnancy and can obstruct venous return leading to edema, varicosities of the leg, or hemorrhoids. The varicosities may not resolve after pregnancy.
This is a common finding and not cause for alarm at this point.
Notification of the health care provider is not warranted at this time.
Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.Rate this question:
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- 11.
When assessing the carotid arteries, the nurse should:
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Palpate both carotid arteries simultaneously to assess for the symmetry of the pulse.
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Palpate firmly to occlude the artery.
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Utilize the bell of the stethoscope to assess for bruits.
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Massage the area noting any masses or hardness.
Correct Answer
A. Utilize the bell of the stethoscope to assess for bruits.Explanation
The bell of the stethoscope is used to assess for the presence of bruits.
Palpation of the carotid pulse should be firm, but not so hard that the artery is occluded.
If both carotid arteries are palpated at the same time, the result can be a drop in blood pressure or a decrease in heart rate due to stimulation of the baroreceptors.
Massage of the area should be avoided due to potential stimulation of the baroreceptors.Rate this question:
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- 12.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Perform a focused assessment and call the health care provider.
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True
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False
Correct Answer
A. FalseExplanation
Calling the health care provider is not indicated with this normal finding.Rate this question:
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- 13.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Assess the thigh blood pressure expecting that it will be lower than that of the arm.
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True
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False
Correct Answer
A. FalseExplanation
In an infant less than one year of age, the systolic blood pressure in the thigh should equal that in the arm.Rate this question:
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- 14.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Ask another nurse to validate the blood pressure because it is low.
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True
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False
Correct Answer
A. FalseExplanation
In a child over one year of age, the systolic pressure in the thigh is 10-40 mm Hg higher than that in the arm.Rate this question:
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- 15.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "These are common and will go away after delivery."
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True
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False
Correct Answer
A. FalseExplanation
This is a common finding and not cause for alarm at this point.Rate this question:
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- 16.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "We need to talk to your health care provider about this."
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True
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False
Correct Answer
A. FalseExplanation
Notification of the health care provider is not warranted at this time.Rate this question:
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- 17.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "This is related to decreased circulation."
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True
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False
Correct Answer
A. FalseExplanation
Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.Rate this question:
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- 18.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "This is related to decreased circulation."
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True
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False
Correct Answer
A. FalseExplanation
Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.Rate this question:
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- 19.
When assessing the carotid arteries, the nurse should utilize the bell of the stethoscope to assess for bruits.
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True
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False
Correct Answer
A. TrueExplanation
The bell of the stethoscope is used to assess for the presence of bruits.Rate this question:
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- 20.
When assessing the carotid arteries, the nurse should palpate both carotid arteries simultaneously to assess for the symmetry of the pulse.
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True
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False
Correct Answer
A. FalseExplanation
If both carotid arteries are palpated at the same time, the result can be a drop in blood pressure or a decrease in heart rate due to stimulation of the baroreceptors.Rate this question:
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- 21.
When assessing the carotid arteries, the nurse should palpate firmly to occlude the artery.
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True
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False
Correct Answer
A. FalseExplanation
Palpation of the carotid pulse should be firm, but not so hard that the artery is occluded.Rate this question:
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- 22.
When assessing the carotid arteries, the nurse should massage the area noting any masses or hardness.
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True
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False
Correct Answer
A. FalseExplanation
Massage of the area should be avoided due to potential stimulation of the baroreceptors.Rate this question:
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- 23.
When assessing the characteristics of the pulse, the nurse notes which of the following? Select all that apply.
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Rate
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Rhythm
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Symmetry
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Amplitude
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Capillary refill
Correct Answer(s)
A. Rate
A. Rhythm
A. Symmetry
A. AmplitudeExplanation
Rate - the number of beats per minute.
Rhythm - the regularity of the beats.
Symmetry - pulses on both sides of the body should be equal.
Amplititude - the strength of the pulse, assessed on a 0-4+ scale.
Capillary refill - Delayed capillary refill is not a characteristic of pulse assessment.Rate this question:
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- 24.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with:
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Venous insufficiency
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Arterial insufficiency
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Thrombophlebitis
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Lymphatic insufficiency
Correct Answer
A. Arterial insufficiencyExplanation
Arterial insufficiency is inadequate circulation in the arterial system, which results in diminished pulses; cool, shiny skin; deep muscle pain; absence of hair on the toes; pallor on elevation; and a red color when dependent.
Venous insufficiency is inadequate circulation in the venous system due to incompetent valves in the deep veins or a blood clot in the veins. Edema is usually present. The temperature of the skin is normal.
Thrombophlebitis is inflammation of a vein with a clot.
Alterations in the lymphatic system may result in lymphedema, not alterations in the arterial circulation such as in arterial insufficiency as described above.Rate this question:
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- 25.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with arterial insufficiency.
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True
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False
Correct Answer
A. TrueExplanation
Arterial insufficiency is inadequate circulation in the arterial system, which results in diminished pulses; cool, shiny skin; deep muscle pain; absence of hair on the toes; pallor on elevation; and a red color when dependent.Rate this question:
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- 26.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with venous insufficiency
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True
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False
Correct Answer
A. FalseExplanation
Venous insufficiency is inadequate circulation in the venous system due to incompetent valves in the deep veins or a blood clot in the veins. Edema is usually present. The temperature of the skin is normal.Rate this question:
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- 27.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with thrombophlebitis。
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True
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False
Correct Answer
A. FalseExplanation
Thrombophlebitis is inflammation of a vein with a clot.Rate this question:
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- 28.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with lymphatic insufficiency
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True
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False
Correct Answer
A. FalseExplanation
Alterations in the lymphatic system may result in lymphedema, not alterations in the arterial circulation such as in arterial insufficiency as described above.Rate this question:
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- 29.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes:
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The presence of varicosities
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Lymphatic abnormalities
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Decreased arterial circulation
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Deep vein thrombosis
Correct Answer
A. Decreased arterial circulationExplanation
Pain associated with arterial insufficiency increases with exercise and is relieved with the cessation of movement.
Varicosities occur in the venous system and are not affected by exercise.
Alterations in the lymphatic system are not exacerbated by exercise.
Deep vein thrombosis is occlusion of a deep vein (e.g., blockage of the femoral vein by a blood clot). The client may have pain and edema that are present both at rest and with exercise.Rate this question:
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- 30.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes decreased arterial circulation.
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True
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False
Correct Answer
A. TrueExplanation
Pain associated with arterial insufficiency increases with exercise and is relieved with the cessation of movement.Rate this question:
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- 31.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes the presence of varicosities.
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True
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False
Correct Answer
A. FalseExplanation
Varicosities occur in the venous system and are not affected by exercise.Rate this question:
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- 32.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes lymphatic abnormalities
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True
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False
Correct Answer
A. FalseExplanation
Alterations in the lymphatic system are not exacerbated by exercise.Rate this question:
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- 33.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes deep vein thrombosis
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True
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False
Correct Answer
A. FalseExplanation
Deep vein thrombosis is occlusion of a deep vein (e.g., blockage of the femoral vein by a blood clot). The client may have pain and edema that are present both at rest and with exercise.Rate this question:
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- 34.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to which of the following assessments?
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Lymphatic
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Respiratory
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Venous
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Arterial
Correct Answer
A. ArterialExplanation
Arterial assessment includes the assessment of the temperature, texture, and moisture of the skin; assessing capillary refill; pulses; and auscultation for bruits.
Lymphatic assessment includes palpating over the various lymph node locations for tenderness or enlargement.
Respiratory assessment includes respiratory rate, auscultation of breath sounds, skin color, and capillary refill.
Venous assessment includes noting the presence of edema, varicosities, and color of the skin.Rate this question:
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- 35.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to arterial.
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True
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False
Correct Answer
A. TrueExplanation
Arterial assessment includes the assessment of the temperature, texture, and moisture of the skin; assessing capillary refill; pulses; and auscultation for bruits.Rate this question:
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- 36.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to lymphatic.
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True
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False
Correct Answer
A. FalseExplanation
Lymphatic assessment includes palpating over the various lymph node locations for tenderness or enlargement.Rate this question:
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- 37.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to respiratory.
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True
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False
Correct Answer
A. FalseExplanation
Respiratory assessment includes respiratory rate, auscultation of breath sounds, skin color, and capillary refill.Rate this question:
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- 38.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to venous.
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True
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False
Correct Answer
A. FalseExplanation
Venous assessment includes noting the presence of edema, varicosities, and color of the skin.Rate this question:
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- 39.
The nurse performs Allen's test to assess which of the following?
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Patency of the radial and ulnar arteries
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Arterial circulation to the lower extremities
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Varicose veins
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Edema
Correct Answer
A. Patency of the radial and ulnar arteriesExplanation
Allen's test determines the patency of the radial and ulnar arteries. To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.
Arterial assessment of the lower extremities would include assessing pulses, color, temperature, and capillary refill.
Varicose veins are assessed by inspection and palpation over the lower extremities for the presence of enlarged, distended veins.
Edema is assessed to determine its extent and whether it is pitting.Rate this question:
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- 40.
The nurse performs Allen's test to assess patency of the radial and ulnar arteries.
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True
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False
Correct Answer
A. TrueExplanation
Allen's test determines the patency of the radial and ulnar arteries.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.Rate this question:
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- 41.
The nurse performs Allen's test to assess arterial circulation to the lower extremities.
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True
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False
Correct Answer
A. FalseExplanation
Arterial assessment of the lower extremities would include assessing pulses, color, temperature, and capillary refill.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.Rate this question:
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- 42.
The nurse performs Allen's test to assess varicose veins.
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True
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False
Correct Answer
A. FalseExplanation
Varicose veins are assessed by inspection and palpation over the lower extremities for the presence of enlarged, distended veins.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.Rate this question:
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- 43.
The nurse performs Allen's test to assess edema.
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True
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False
Correct Answer
A. FalseExplanation
Edema is assessed to determine its extent and whether it is pitting.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.Rate this question:
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- 44.
A client's blood pressure is 158/90 mm Hg. What does this reading suggest to the nurse?
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This blood pressure is normal.
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This client has prehypertension.
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This client has stage 1 hypertension.
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This client has stage 2 hypertension.
Correct Answer
A. This client has stage 1 hypertension.Explanation
In stage 1 hypertension, the systolic reading is between 140 to 159 mm Hg and the diastolic reading is between 90 to 99 mm Hg.
Normal blood pressure values are systolic blood pressureRate this question:
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- 45.
When performing an assessment on a client with COPD the nurse notes the presence of clubbing. Which of the following is noted in this condition? Select all that apply.
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Fingertips large and round
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Delayed capillary refill
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Flattening of the angle of the nail
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Delayed Allen's test
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Base of the nail feels spongy
Correct Answer(s)
A. Fingertips large and round
A. Flattening of the angle of the nail
A. Base of the nail feels spongyExplanation
Fingertips large and round - Enlargement of the tips of the fingers occurs with clubbing. Clubbing is a sign of oxygen deprivation in the extremities.
Delayed capillary refill - This is seen with circulatory problems and is not a sign of clubbing.
Flattening of the angle of the nail - This is seen with clubbing. Clubbing is a sign of oxygen deprivation in the extremities.
Delayed Allen's test - This occurs with alterations in radial and ulnar artery circulation, not clubbing.
Base of the nail feels spongy - The base of the nail feels spongy with clubbing. Clubbing is a sign of oxygen deprivation in the extremities.Rate this question:
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- 46.
A client is being evaluated for suspected thrombosis of a deep leg vein. Which of the following is the nurse most likely to note during the assessment?
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Pain in the calf when dorsiflexing the foot
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A cool foot with diminished pulses
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Increased pain with elevation of the extremity
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Decreased hair distribution on the legs
Correct Answer
A. Pain in the calf when dorsiflexing the footExplanation
Pain in the calf when dorsiflexing the foot (Homans' sign) may indicate thrombosis (blood clot) of a deep leg vein.
A cool foot with diminished pulses indicates problems with arterial circulation, not venous circulation.
Increased pain with elevation of the extremity would be present with arterial circulation abnormalities.
Decreased hair distribution on the lower legs is related to arterial abnormalities, not venous.Rate this question:
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- 47.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has pain in the calf when dorsiflexing the foot.
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True
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False
Correct Answer
A. TrueExplanation
Pain in the calf when dorsiflexing the foot (Homans' sign) may indicate thrombosis (blood clot) of a deep leg vein.Rate this question:
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- 48.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has a cool foot with diminished pulses.
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True
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False
Correct Answer
A. FalseExplanation
A cool foot with diminished pulses indicates problems with arterial circulation, not venous circulation.Rate this question:
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- 49.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has increased pain with elevation of the extremity.
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True
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False
Correct Answer
A. FalseExplanation
Increased pain with elevation of the extremity would be present with arterial circulation abnormalities.Rate this question:
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Mar 03, 2023Quiz Edited by
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Apr 15, 2012Quiz Created by
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