Ch18 Peripheral Vascular System

1. The nurse performs Allen's test to assess varicose veins.

True

False

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.

Explanation

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.

2. When assessing the carotid arteries, the nurse should utilize the bell of the stethoscope to assess for bruits.

True

False

The bell of the stethoscope is used to assess for the presence of bruits.

Explanation

The bell of the stethoscope is used to assess for the presence of bruits.

3. The nurse performs Allen's test to assess patency of the radial and ulnar arteries.

True

False

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.

Explanation

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.

4. 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

True

False

Alterations in the lymphatic system may result in lymphedema, not alterations in the arterial circulation such as in arterial insufficiency as described above.

Explanation

Alterations in the lymphatic system may result in lymphedema, not alterations in the arterial circulation such as in arterial insufficiency as described above.

5. Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to lymphatic.

True

False

Lymphatic assessment includes palpating over the various lymph node locations for tenderness or enlargement.

Explanation

Lymphatic assessment includes palpating over the various lymph node locations for tenderness or enlargement.

6. The nurse performs Allen's test to assess edema.

True

False

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.

Explanation

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.

7. 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.

True

False

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.

Explanation

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.

8. When palpating a client's pulse, the nurse notes that strength of the pulse alternates between strong and weak pulsations. The nurse would document the presence of pulsus alternans.

True

False

Pulsus alternans is the term used for alternating strong and weak pulses, which can occur in conditions such as aortic regurgitation.

Explanation

Pulsus alternans is the term used for alternating strong and weak pulses, which can occur in conditions such as aortic regurgitation.

9. Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to respiratory.

True

False

Respiratory assessment includes respiratory rate, auscultation of breath sounds, skin color, and capillary refill.

Explanation

Respiratory assessment includes respiratory rate, auscultation of breath sounds, skin color, and capillary refill.

10. When assessing the carotid arteries, the nurse should palpate firmly to occlude the artery.

True

False

Palpation of the carotid pulse should be firm, but not so hard that the artery is occluded.

Explanation

Palpation of the carotid pulse should be firm, but not so hard that the artery is occluded.

11. 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

True

False

Alterations in the lymphatic system are not exacerbated by exercise.

Explanation

Alterations in the lymphatic system are not exacerbated by exercise.

12. 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.

True

False

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.

Explanation

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.

13. An elderly client has lower-extremity edema and thick skin discolored to a dark brown. The client complains of his legs feeling "full." The client may have an arterial aneurysm.

True

False

Arterial aneurysms are located in arteries and can sometimes be detected by the presence of a bruit.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

Explanation

Arterial aneurysms are located in arteries and can sometimes be detected by the presence of a bruit.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

14. Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to arterial.

True

False

Arterial assessment includes the assessment of the temperature, texture, and moisture of the skin; assessing capillary refill; pulses; and auscultation for bruits.

Explanation

Arterial assessment includes the assessment of the temperature, texture, and moisture of the skin; assessing capillary refill; pulses; and auscultation for bruits.

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, "We need to talk to your health care provider about this."

True

False

Notification of the health care provider is not warranted at this time.

Explanation

Notification of the health care provider is not warranted at this time.

16. The nurse performs Allen's test to assess which of the following?

Patency of the radial and ulnar arteries

Arterial circulation to the lower extremities

Varicose veins

Edema

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.

Explanation

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.

17. The nurse performs Allen's test to assess arterial circulation to the lower extremities.

True

False

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.

Explanation

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.

18. A client is being evaluated for suspected thrombosis of a deep leg vein. Client has pain in the calf when dorsiflexing the foot.

True

False

Pain in the calf when dorsiflexing the foot (Homans' sign) may indicate thrombosis (blood clot) of a deep leg vein.

Explanation

Pain in the calf when dorsiflexing the foot (Homans' sign) may indicate thrombosis (blood clot) of a deep leg vein.

19. Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to venous.

True

False

Venous assessment includes noting the presence of edema, varicosities, and color of the skin.

Explanation

Venous assessment includes noting the presence of edema, varicosities, and color of the skin.

20. 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.

True

False

Calling the health care provider is not indicated with this normal finding.

Explanation

Calling the health care provider is not indicated with this normal finding.

21. 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.

True

False

Varicosities occur in the venous system and are not affected by exercise.

Explanation

Varicosities occur in the venous system and are not affected by exercise.

22. A client is being evaluated for suspected thrombosis of a deep leg vein. Client has decreased hair distribution on the legs

True

False

Decreased hair distribution on the lower legs is related to arterial abnormalities, not venous.

Explanation

Decreased hair distribution on the lower legs is related to arterial abnormalities, not venous.

23. 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

True

False

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.

Explanation

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.

24. 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?

Lymphatic

Respiratory

Venous

Arterial

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.

Explanation

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.

25. When performing an assessment, the nurse notes the presence of decreased pulses. The nurse knows that:

It is caused by an infection.

It is caused by blood pooling in the legs.

It is caused by a blood clot in the lower leg.

It is caused by decreased arterial circulation.

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.

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.

26. 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

True

False

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.

Explanation

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.

27. When assessing the carotid arteries, the nurse should massage the area noting any masses or hardness.

True

False

Massage of the area should be avoided due to potential stimulation of the baroreceptors.

Explanation

Massage of the area should be avoided due to potential stimulation of the baroreceptors.

28. 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?

"These are common and will go away after delivery."

"We need to talk to your health care provider about this."

"This is a normal finding and is caused by pressure from your uterus delaying blood return from your legs."

"This is related to decreased circulation."

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.

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.

29. When assessing the carotid arteries, the nurse should palpate both carotid arteries simultaneously to assess for the symmetry of the pulse.

True

False

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.

Explanation

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.

30. The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Which of the following should the nurse do?

Continue with the assessment as this is a normal neonatal blood pressure reading.

Perform a focused assessment and call the health care provider.

Assess the thigh blood pressure expecting that it will be lower than that of the arm.

Ask another nurse to validate the blood pressure because it is low.

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.

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.

31. When palpating a client's pulse, the nurse notes that strength of the pulse alternates between strong and weak pulsations. The nurse would document the presence of weak/thready pulsations.

True

False

Weak/thready pulsations are very difficult to palpate and occur in conditions such as shock.

Explanation

Weak/thready pulsations are very difficult to palpate and occur in conditions such as shock.

32. When palpating a client's pulse, the nurse notes that strength of the pulse alternates between strong and weak pulsations. The nurse would document the presence of pulsus paradoxus.

True

False

Pulsus paradoxus is the reduced intensity of the pulse during inspiration versus expiration which can occur in conditions such as cardiac tamponade.

Explanation

Pulsus paradoxus is the reduced intensity of the pulse during inspiration versus expiration which can occur in conditions such as cardiac tamponade.

33. 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。

True

False

Thrombophlebitis is inflammation of a vein with a clot.

Explanation

Thrombophlebitis is inflammation of a vein with a clot.

34. 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.

True

False

In an infant less than one year of age, the systolic blood pressure in the thigh should equal that in the arm.

Explanation

In an infant less than one year of age, the systolic blood pressure in the thigh should equal that in the arm.

35. An elderly client has lower-extremity edema and thick skin discolored to a dark brown. The client complains of his legs feeling "full." The client may have varicose veins.

True

False

Varicose veins are distended veins and are not directly related to the signs and symptoms the client is experiencing.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

Explanation

Varicose veins are distended veins and are not directly related to the signs and symptoms the client is experiencing.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

36. 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

Arterial insufficiency

Thrombophlebitis

Lymphatic insufficiency

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.

Explanation

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.

37. When assessing the carotid arteries, the nurse should:

Palpate both carotid arteries simultaneously to assess for the symmetry of the pulse.

Palpate firmly to occlude the artery.

Utilize the bell of the stethoscope to assess for bruits.

Massage the area noting any masses or hardness.

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.

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.

38. An elderly client has lower-extremity edema and thick skin discolored to a dark brown. The client complains of his legs feeling "full." The client might have venous insufficiency.

True

False

Venous insufficiency is inadequate circulation in the venous system.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

Explanation

Venous insufficiency is inadequate circulation in the venous system.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

39. An elderly client has lower-extremity edema and thick skin discolored to a dark brown. The client complains of his legs feeling "full." The client might have arterial insufficiency.

True

False

Alterations in arterial circulation would produce a cool skin temperature and diminished pulses.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

Explanation

Alterations in arterial circulation would produce a cool skin temperature and diminished pulses.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

40. 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?

The forearm and hand for infection or inflammation

The lower legs for injury

The equality of radial pulse

Capillary refill and temperature of the extremities

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.

Explanation

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.

41. 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

Lymphatic abnormalities

Decreased arterial circulation

Deep vein thrombosis

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.

Explanation

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.

42. When palpating a client's pulse, the nurse notes that strength of the pulse alternates between strong and weak pulsations. The nurse would document the presence of unequal pulses.

True

False

Unequal pulses occur when there is difference in amplitude between the right and left pulses.

Explanation

Unequal pulses occur when there is difference in amplitude between the right and left pulses.

43. 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.

True

False

Pain associated with arterial insufficiency increases with exercise and is relieved with the cessation of movement.

Explanation

Pain associated with arterial insufficiency increases with exercise and is relieved with the cessation of movement.

44. 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."

True

False

Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.

Explanation

Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.

45. 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."

True

False

Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.

Explanation

Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.

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?

Pain in the calf when dorsiflexing the foot

A cool foot with diminished pulses

Increased pain with elevation of the extremity

Decreased hair distribution on the legs

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.

Explanation

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.

47. A client's blood pressure is 158/90 mm Hg. What does this reading suggest to the nurse?

This blood pressure is normal.

This client has prehypertension.

This client has stage 1 hypertension.

This client has stage 2 hypertension.

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 pressure
Prehypertension is classified as a systolic reading of 120-139 or a diastolic reading of 80-89.

Stage 2 hypertension is classified as systolic blood pressure greater than or equal to 160, or a diastolic pressure greater than or equal to 100.

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 pressure
Prehypertension is classified as a systolic reading of 120-139 or a diastolic reading of 80-89.

Stage 2 hypertension is classified as systolic blood pressure greater than or equal to 160, or a diastolic pressure greater than or equal to 100.

48. 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."

True

False

This is a common finding and not cause for alarm at this point.

Explanation

This is a common finding and not cause for alarm at this point.

49. A client is being evaluated for suspected thrombosis of a deep leg vein. Client has a cool foot with diminished pulses.

True

False

A cool foot with diminished pulses indicates problems with arterial circulation, not venous circulation.

Explanation

A cool foot with diminished pulses indicates problems with arterial circulation, not venous circulation.

50. When palpating a client's pulse, the nurse notes that strength of the pulse alternates between strong and weak pulsations. The nurse would document the presence of which of the following?

Weak/thready pulsations

Unequal pulses

Pulsus alternans

Pulsus paradoxus

Pulsus alternans is the term used for alternating strong and weak pulses, which can occur in conditions such as aortic regurgitation.

Weak/thready pulsations are very difficult to palpate and occur in conditions such as shock.

Unequal pulses occur when there is difference in amplitude between the right and left pulses.

Pulsus paradoxus is the reduced intensity of the pulse during inspiration versus expiration which can occur in conditions such as cardiac tamponade.

Explanation

Pulsus alternans is the term used for alternating strong and weak pulses, which can occur in conditions such as aortic regurgitation.

Weak/thready pulsations are very difficult to palpate and occur in conditions such as shock.

Unequal pulses occur when there is difference in amplitude between the right and left pulses.

Pulsus paradoxus is the reduced intensity of the pulse during inspiration versus expiration which can occur in conditions such as cardiac tamponade.

51. An elderly client has lower-extremity edema and thick skin discolored to a dark brown. The client complains of his legs feeling "full." Which of the following does this information suggest to the nurse?

The client may have varicose veins.

The client might have venous insufficiency.

The client might have arterial insufficiency.

The client may have an arterial aneurysm.

Venous insufficiency is inadequate circulation in the venous system.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

Varicose veins are distended veins and are not directly related to the signs and symptoms the client is experiencing.

Alterations in arterial circulation would produce a cool skin temperature and diminished pulses.

Arterial aneurysms are located in arteries and can sometimes be detected by the presence of a bruit.

Explanation

Venous insufficiency is inadequate circulation in the venous system.
Edema is usually present and is accompanied by a feeling of leg fullness. The skin around the ankles may be thicker and have a brown discoloration.

Varicose veins are distended veins and are not directly related to the signs and symptoms the client is experiencing.

Alterations in arterial circulation would produce a cool skin temperature and diminished pulses.

Arterial aneurysms are located in arteries and can sometimes be detected by the presence of a bruit.

52. A client is being evaluated for suspected thrombosis of a deep leg vein. Client has increased pain with elevation of the extremity.

True

False

Increased pain with elevation of the extremity would be present with arterial circulation abnormalities.

Explanation

Increased pain with elevation of the extremity would be present with arterial circulation abnormalities.

53. 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?

The forearm and hand for infection or inflammation

The lower legs for injury

The equality of radial pulse

Capillary refill and temperature of the extremities

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.

Explanation

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.

54. 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?

The forearm and hand for infection or inflammation

The lower legs for injury

The equality of radial pulse

Capillary refill and temperature of the extremities

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.

Explanation

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.

55. When performing an assessment, the nurse notes the presence of inflammation and edema over the affected area. The nurse knows that:

It is caused by an infection.

It is caused by blood pooling in the legs.

It is caused by a blood clot in the lower leg.

It is caused by decreased arterial circulation.

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.

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.

56. When performing an assessment, the nurse notes the presence of ankle edema bilaterally. The nurse knows that:

It is caused by an infection.

It is caused by blood pooling in the legs.

It is caused by a blood clot in the lower leg.

It is caused by decreased arterial circulation.

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.

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.

57. When assessing the characteristics of the pulse, the nurse notes which of the following? Select all that apply.

Rate

Rhythm

Symmetry

Amplitude

Capillary refill

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.

Explanation

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.

Submit

58. 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?

The forearm and hand for infection or inflammation

The lower legs for injury

The equality of radial pulse

Capillary refill and temperature of the extremities

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.

Explanation

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.

59. 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.

Fingertips large and round

Delayed capillary refill

Flattening of the angle of the nail

Delayed Allen's test

Base of the nail feels spongy

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.

Explanation

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.

Submit

60. When performing an assessment, the nurse notes the presence of edema in the affected extremity. The nurse knows that:

It is caused by an infection.

It is caused by blood pooling in the legs.

It is caused by a blood clot in the lower leg.

It is caused by decreased arterial circulation.

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.

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.