Deck 20: Peripheral Vascular System

Question 1

While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech. The vital signs are BP 160/88 mmHg, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which responses by the nurse are appropriate in this situation?

A) "I'm going to take your temperature now."
B) "Have you ever experienced chest pain?"
C) "Are you feeling any anxiety right now?"
D) "Are you experiencing any pain at this time?"
E) "Have you ever been diagnosed with hypothyroidism?"

Answer 1

"Have you ever experienced chest pain?"
"Are you feeling any anxiety right now?"
"Are you experiencing any pain at this time?"

Question 2

The nurse is assessing the blood pressure of a client. The nurse obtains the blood pressure in both of the client's arms. The nurse determines that there is a difference of 15 mmHg in the systolic readings between the arms and repeats the assessment with the same results. Based on this data, which does the nurse suspect?

A) Inaccurate technique.
B) Anxiety.
C) Unilateral arterial obstruction.
D) Shock.

Answer 2

Unilateral arterial obstruction.

Question 3

The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery. Which test may be used to help determine the patency of this artery?

A) Trendelenburg test.
B) Manual compression test.
C) Homan sign.
D) Allen test.

Answer 3

Allen test.

Question 4

The client was recently diagnosed with venous insufficiency. Which client statements support the client's diagnosis?

A) "My legs are so cold that they feel like ice."
B) "My ankles and feet are always swollen."
C) "The skin on my leg looks so pale."
D) "When I walk around a lot, my legs just ache."
E) "I have an ulcer on my inner leg above my ankle that just bleeds and bleeds."

Question 5

The nurse is assessing a client's blood pressure. The client asks the nurse why it is important to feel for his pulse prior to taking his blood pressure. Which response by the nurse is the most appropriate?

A) "I can document this value if I am unable to measure your blood pressure the other way."
B) "I need to feel for your pulse because you doctor said you are developing symptoms of shock."
C) "I am more likely to get an accurate reading if I do it this way."
D) "It is the best way to determine an arterial obstruction."

Question 6

The nurse is assessing a client admitted to the hospital for congestive heart failure (CHF) and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the client's ankles. The client's history indicates that the client has had a myocardial infarction and a left mastectomy. Which is the most probable cause of the edema in the client's left arm?

A) Impaired lymphatic drainage.
B) Noncompliance with medication regimen.
C) Right-sided heart failure.
D) Excessive intake of sodium.

Question 7

While assessing a client with a laceration on the client's left third finger, the nurse notes the presence of inflammation and swelling of the finger. Which other assessment findings might the nurse expect based on this initial data?

A) 1 cm, nontender, soft, left brachial node.
B) 2 cm, tender, firm, left superior superficial inguinal node.
C) 2 cm, tender, firm, left epitrochlear node.
D) 2 cm, nontender, firm, left ulnar node.
E) 2 cm, tender, firm, left axillary lymph node.

Question 8

The nurse educator is teaching a group of nursing students how to perform an assessment of the client's peripheral vascular system. Which student statements indicate an appropriate understanding of the peripheral vascular assessment?

A) "I need to take a blood pressure only in the client's right arm."
B) "The best way to assess the carotid pulses is palpate one side and then the other."
C) "It will be easier to assess the client's carotid pulses if the client is obese."
D) "I should inspect the arms to ensure that they are close to the same size."
E) "I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions."

Question 9

A female client being examined by the nurse exhibits 2+ pitting edema in the right arm, while the left arm is normal in size. Which question by the nurse is the most appropriate based on this data?

A) "How much salt do you have in your diet?"
B) "Does the other arm swell also?"
C) "What surgical procedures have you had?"
D) "Do you ever feel self-conscious about your arm?"

Question 10

The nurse is preparing to assess the client's dorsalis pedis pulse. Which location will the nurse palpate to assess this pulse?

A) A.
B) B.
C) C.
D) D.

Question 11

The nurse is documenting an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. Which other assessment data would be useful to determine the origin of this client's ulcer?

A) Skin turgor.
B) Calf measurements.
C) Homan's sign.
D) Peripheral pulses.

Question 12

A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. Which response by the nurse is the most appropriate?

A) "Your lymph nodes filter blood for your body."
B) "They are responsible for the break down of old red blood cells."
C) "They make lymphocytes for you."
D) "Your lymph nodes help to remove infectious organisms."

Question 13

The nurse is educating a client about blood pressure values. Which statement by the client indicates appropriate understanding of the teaching session?

A) "A normal blood pressure always depends on my previous blood pressure values."
B) "A normal blood pressure is below 140/90."
C) "If I was diagnosed with prehypertension my blood pressure would be 138/89."
D) "A diagnosis of prehypertension does not increase my risk of developing hypertension."

Question 14

The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which statements by the client will the nurse document as risk factors for varicose vein development?

A) "My mother had big veins on her legs from the time I was little."
B) "My father is of Japanese descent."
C) "I'm a hair stylist."
D) "I was pregnant once and have a son."
E) "I know I weigh a lot more than I should."

Question 15

The nurse is completing an assessment on a client following a cardiac catheterization procedure. During the initial assessment, the nurse easily palpates the client's right dorsalis pedis and posterior tibial pulses. The pulses on the client's left leg are strong and easily palpable. During the next assessment, the nurse is unable to palpate or find these pulses on the right side with a Doppler. Which is the priority action by the nurse based on this data?

A) Notify the healthcare provider immediately.
B) Assess for the client's right popliteal pulse.
C) Take the client's blood pressure.
D) Place the client in Trendelenburg position.

Question 16

The nurse is thoroughly assessing the client for any peripheral vascular problems. The client requested the nurse to state exactly what the nurse was looking for during the assessment. Which statements by the nurse are appropriate to include in the assessment process?

A) "I am feeling your feet to see how warm they are."
B) "I am looking for hair on your toes."
C) "I am going to perform the Trendelenburg's test to see how well the radial and ulnar arteries are supplying blood to your hand."
D) "I am going to test your ability to feel sensations by giving you an injection."
E) "I am going to perform the Allen's test to see if you have any varicose veins."

Question 17

While performing the assessment of the client's peripheral vascular system, the nurse notes that there was a rapid filling of superficial veins during the Trendelenburg test. This data is consistent with which disorder?

A) Valve incompetence.
B) Arterial insufficiency.
C) Venous insufficiency.
D) Phlebitis.

Question 18

The nurse is performing an assessment of the client's peripheral vascular system. Which actions by the nurse are appropriate when assessing this client?

A) Assessing the client in a flat, supine position when the client exhibits a respiratory rate of 26 breaths/min. with a dusky appearance around the mouth and lips.
B) Requesting the client remove all undergarments prior to putting the gown.
C) Assessing pedal pulses over the client's socks.
D) Taking a blood pressure cuff, Doppler, and stethoscope into the client's room for the assessment.

Question 19

The nurse examines the peripheral vascular system of a client diagnosed with chronic bronchitis 22 years ago. The nurse examines the client's hand. Which statement by the client is consistent with the client's diagnosis?

A) "My fingers look so pointy and narrow at the ends."
B) "My fingernails are as hard as a rock."
C) "My nails always look a little bluish."
D) "My nails have a lot of strange ridges in them."

Question 20

The client is visiting the healthcare provider's office with complaints of discoloration of her hands. The client states, "My fingertips turn whitish and then later they get really red." Which disorder does the nurse anticipate the client will be diagnosed with based on this data?

A) Lymphedema.
B) Raynaud disease.
C) Thrombosis.
D) Venous insufficiency.

Question 21

The nurse is performing an assessment on a healthy preschool-age client and palpates two enlarged lymph nodes on the child's neck. The lymph nodes are soft, mobile, nontender, and each is less than 1 cm in diameter. Which action by the nurse is the most appropriate?

A) Assess for an infected wound.
B) Document this as a normal finding.
C) Notify the healthcare provider.
D) Obtain an order for a throat culture.

Question 22

An adult female client wishes to begin taking oral contraceptives. The medical history indicates that the client had a deep vein thrombosis three years ago. After reviewing the objectives set forth in Healthy People 2020, which response by the nurse is the most appropriate?

A) "We can have the healthcare provider write you a prescription today."
B) "You will also have to take blood thinners."
C) "I need to perform a Homan's test on you."
D) "Taking oral contraceptives increases your risk of developing clots."

Question 23

The nurse is caring for a male client who is complaining of dizziness when standing. The client has been compliant with his antihypertensive medication. Which statements made by the client are commonly associated with the use of antihypertensive medication?

A) "Sometimes, I just feel so sick to my stomach."
B) "I have frequent headaches."
C) "My sex life hasn't been so good since I started taking this medication."
D) "I have a rash all over my back."
E) "I don't seem to urinate as much as I did before I started this medication."

Question 24

The nurse is performing a peripheral vascular assessment of a female client who is 7 months pregnant. The nurse notes mild peripheral edema, all other findings were normal. Which action by the nurse is appropriate based on this assessment data?

A) Notify the healthcare provider immediately regarding this abnormal finding.
B) Obtain an order from the healthcare provider for a diuretic to reduce the client's edema.
C) Document the findings as expected due to the client's pregnancy.
D) Educate the client regarding ways to reduce the risk about peripheral vascular ulcer development.

Question 25

A client's blood pressure is 138/86 mmHg. Which will the nurse use when documenting this finding in the client's medical record?

A) The client has normal blood pressure.
B) The client is exhibiting prehypertension.
C) The client is exhibiting stage I hypertension.
D) The client is exhibiting stage II hypertension.

Question 26

An adult female client develops a pulmonary embolism and is admitted to the intensive care unit (ICU). While completing the client's health history interview, which data is consistent with the admitting diagnosis of pulmonary embolism?

A) Client states, "I am not a smoker."
B) Client states, "The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldn't."
C) Client states, "I had an open appendectomy 4 days ago." A 4 cm incision noted to RLQ, staples intact, edges well-approximated.
D) Client states, "I have taken oral contraceptives for the last 7 years."
E) Client states, "I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care."

Question 27

The client developed a pulmonary embolism. In which most distal area of the lower extremity did the embolism likely originate?

A) A.
B) B.
C) C.
D) D.

Question 28

The nurse is conducting a wellness presentation for a group of factory employees and notes a large number of African Americans present. Based on information included in Healthy People 2020, which topic is a priority for this population?

A) Cancer risk reduction.
B) Bone density assessments.
C) Smoking cessation.
D) Blood pressure screening.