Deck 18: Peripheral Vascular System

Question 1

A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures.The nurse would respond with which of the following statements?
1)"Your lymph nodes filter blood for your body."
2)"They are responsible for the break down of old red blood cells."
3)"They make lymphocytes for you."
4)"Your lymph nodes help to remove infectious organisms."

Answer 1

4

Question 2

The nurse is preparing to assess the client's dorsalis pedis pulse.Draw an arrow to where this pulse can be palpated on the following figure.

Answer 2

Question 3

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 of the following would be the most appropriate action for the nurse at this time?
1)Notify the healthcare provider immediately.
2)Assess for the client's right popliteal pulse.
3)Take the client's blood pressure.
4)Place the client in Trendelenburg position.

Answer 3

2

Question 4

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,apical pulse 102 beats per minute,respiratory rate 26 per minute.Which of the following are appropriate responses by the nurse?
1)"I'm going to take your temperature now."
2)"Have you ever experienced chest pain?"
3)"Are you feeling any anxiety right now?"
4)"Are you experiencing any pain at this time?"
5)"Have you ever been diagnosed with hypothyroidism?"

Question 5

The client was recently diagnosed with venous insufficiency.Which of the following statements by the client are consistent with this diagnosis?
1)"My legs are so cold that they feel like ice."
2)"My ankles and feet are always swollen."
3)"The skin on my leg looks so pale."
4)"When I walk around a lot,my legs just ache."
5)"I have an ulcer on my inner leg above my ankle that just bleeds and bleeds."

Question 6

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 of the following statements by the client is consistent with the client's diagnosis?
1)"My fingers look so pointy and narrow at the ends."
2)"My fingernails are as hard as a rock."
3)"My nails always look a little bluish."
4)"My nails have a lot of strange ridges in them."

Question 7

The nurse is performing the assessment of an elderly client recently diagnosed with arterial insufficiency due to atherosclerosis.Which of the following findings are consistent with this condition?
1)Bilateral pitting edema 3+ in ankles and feet
2)Carotid bruit present
3)Blood pressure 180/94
4)Peripheral pulses 1+/4+ in dorsalis pedis bilaterally
5)A pea-sized ulcer noted on the client's right great toe,no drainage,well-defined edges

Question 8

The nurse is assessing a client who may have arterial insufficiency in the left lower leg.Which of the following are consistent with this diagnosis?
1)Left dorsalis pedis pulse +1,right dorsalis pedis pulse +3
2)Skin is cool,tight,and shiny
3)When left leg is dependent,erythema is present
4)When left leg is elevated,pallor is present
5)Client complains of increased pain during rest periods

Question 9

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." The nurse is not surprised to learn from the healthcare provider that the client has which of the following disorders?
1)Lymphedema
2)Raynaud's disease
3)Thrombosis
4)Venous insufficiency

Question 10

The student nurse is preparing to perform an assessment of the client's peripheral vascular system.The experienced nurse asks the student nurse questions to ensure the student nurse has prepared adequately.Which of the following statements by the student nurse indicate that further education is required?
1)"I need to take a blood pressure only in the client's right arm."
2)"The best way to assess the carotid pulses is palpate one side and then the other."
3)"It will be easier to assess the client's carotid pulses if the client is obese."
4)I should inspect the arms to ensure that they are close to the same size."
5)"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 11

The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins.Which of the following statements by the client are associated with risk factors for varicose veins?
1)"My mother had big veins on her legs from the time I was little."
2)"My father is of Japanese descent."
3)"I'm a hair stylist."
4)"I was pregnant once and have a son."
5)"I know I weigh a lot more than I should."

Question 12

The nurse is documenting about 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.To help determine information about the origin of the client's ulcer,which of the following pieces of the assessment will be most useful for the nurse?
1)Skin turgor
2)Calf measurements
3)Homan's sign
4)Peripheral pulses

Question 13

The nursing student is learning about blood pressure assessment and asks the instructor about blood pressure values.Which of the following responses is an accurate response?
1)"A normal blood pressure always depends on the client's previous values."
2)"A normal blood pressure is below 140/90."
3)"A client with prehypertension has a blood pressure that is greater than 140/90."
4)"A client with stage II hypertension has a blood pressure that is greater than 160/100."

Question 14

The nurse is assessing a client admitted to the hospital for congestive heart failure 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.The nurse would suspect which of the following causes for the edema in the left arm?
1)Impaired lymphatic drainage
2)Noncompliance with medication regimen
3)Right-sided heart failure
4)Excessive intake of sodium

Question 15

The student nurse is performing an assessment of the client's peripheral vascular system with the experienced nurse's guidance.Which of the following actions by the student nurse indicate that the student nurse requires further education?
1)The student nurse continues to assess the client while the client is in a flat,supine position.The client's respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips.
2)The student nurse requests that the client remove all undergarments prior to putting the gown.
3)The client left her socks on and the student nurse assesses the client's pedal pulses over the socks.
4)The client is wearing multiple rings and bracelets.The student nurse states that she may leave them on during the examination.
5)The student nurse takes a blood pressure cuff,Doppler,and stethoscope into the client's room for this assessment.

Question 16

The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery.Which of the following tests may be used to help determine the patency of this artery?
1)Trendelenburg test
2)Manual compression test
3)Homan's sign
4)Allen's test

Question 17

The nurse is taking 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 mm Hg in the systolic readings between the arms and repeats the assessment with the same results.The nurse suspects which of the following may have occurred in this situation?
1)Inaccurate technique
2)Anxiety
3)Unilateral arterial obstruction
4)Shock

Question 18

The nursing student is learning about the appropriate method to use when assessing a client's blood pressure.The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure.Which of the following is the nursing instructor's best response?
1)"You can document this value if you cannot hear the blood pressure well."
2)"This needs to be done only when the client is developing clinical manifestations associated with shock."
3)"You are more likely to get an accurate reading when you do it this way."
4)"It is the best way to determine an arterial obstruction."

Question 19

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.The nurse might expect to find which of the following?
1)1cm,nontender,soft,left brachial node
2)cm,tender,firm,left superior superficial inguinal node
3)2 cm,tender,firm,left epitrochlear node
4)cm,nontender,firm,left ulnar node
5)cm,tender,firm,left axillary lymph node

Question 20

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 of the following statements by the nurse are unexpected?
1)"I am feeling your feet to see how warm they are."
2)I am looking for hair on your toes."
3)I am going to perform the Trendelenburg's test to see how well the radial and ulnar arteries are supplying blood to your hand."
4)I am going to test your ability to feel sensations by giving you an injection."
5)"I am going to perform the Allen's test to see if you have any varicose veins."

Question 21

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 of the following actions by the nurse would be appropriate?
1)Notify the healthcare provider immediately regarding this abnormal finding.
2)Obtain an order from the healthcare provider for a diuretic to reduce the client's edema.
3)Document the findings as expected due to the client's pregnancy.
4)Educate the client regarding ways to reduce the risk about peripheral vascular ulcer development.

Question 22

The client is a 38-year-old female client who developed a pulmonary embolism and is currently in the Intensive Care Unit.The nurse in the Intensive Care Unit is interviewing the client and reviewing her history.Which of the following statements by the client or assessment findings are consistent with the client's increased risk for developing a pulmonary embolism?
1)Client states,"I usually smoke two packs of cigarettes each day."
2)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."
3)Client states,"I had an open appendectomy 4 days ago." 4 cm incision noted to RLQ,staples intact,edges well-approximated
4)Client states,"I have taken oral contraceptives for the last 7 years."
5)Client states,"I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care."

Question 23

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 of the following responses by the nurses is most important at this time?
1)"How much salt do you have in your diet?"
2)"Does the other arm swell also?"
3)"Tell me about your past surgical procedures."
4)"Do you ever feel self-conscious about your arm?"

Question 24

A[1][2] 31-year-old 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 of the following is the best response by the nurse?
1)"We can have the healthcare provider write you a prescription today."
2)"You will also have to take blood thinners."
3)"I need to perform a Homan's test on you."
4)"Taking oral contraceptives increases your risk of developing clots."

Question 25

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 of the following statements by the client are commonly associated with antihypertensive medication use?
1)"Sometimes,I just feel so sick to my stomach."
2)"I have frequent headaches."
3)"My sex life hasn't been so good since I started taking this medication."
4)"I have a rash all over my back."
5)"I don't seem to pee as much as I did before I started this medication."

Question 26

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.These findings would be most consistent with which of the following disorders?
1)Valve incompetence
2)Arterial insufficiency
3)Venous insufficiency
4)Phlebitis

Question 27

The nurse is performing an assessment on a healthy 5 year old 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.The nurse would choose which of the following actions in this situation?
1)Assess for an infected wound.
2)Document this as a normal finding.
3)Notify the healthcare provider.
4)Obtain an order for a throat culture.

Question 28

The client developed a pulmonary embolism.Draw an arrow pointing toward the most distal area of the lower extremity from where the embolism most likely originated.

Question 29

A client's blood pressure is 138/86 mm Hg.The nurse classifies this client's blood pressure as which of the following categories?
1)Normal
2)Prehypertension
3)Stage I hypertension
4)Stage II hypertension

Question 30

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,the nurse would choose which of the following topics as a priority for this setting?
1)Cancer risk reduction
2)Bone density assessments
3)Smoking cessation
4)Blood pressure screening