Deck 19: Peripheral Vascular System

Question 1

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.

Answer 1

Raynaud disease.

Question 2

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

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."

Answer 2

"My ankles and feet are always swollen."
"I have an ulcer on my inner leg above my ankle that just bleeds and bleeds."

Question 3

Which question should the nurse ask the client that is associated with a diagnosis of chronic bronchitis?

A) "How long have your fingertips been this large?"
B) "How long have your fingernails been so hard?"
C) "How long have your nails been a bluish color?"
D) "How long have your nails had ridges in them?"

Answer 3

"How long have your nails been a bluish color?"

Question 4

The nurse is preparing to assess the arteriovenous fistula of a client scheduled for dialysis. Which findings should the nurse anticipate?

A) Cool shiny skin.
B) Discoloration of the area.
C) Unilateral edema.
D) Bulging veins near the surface of the skin.

Question 5

The nurse obtaining a blood pressure in both of the client's arms 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.

Question 6

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 7

The nurse is teaching a client what they can expect during the peripheral vascular assessment of the lower extremities. Which statements by the nurse are appropriate to include in the teaching? Select all that apply.

A) "I am going to touch your legs and feet to see how warm they are."
B) "I will be assessing your legs for hair loss."
C) "I will be using a Doppler to find your pulses."
D) "I am going to test your ability to feel sensations."
E) "I will be looking for varicose veins."

Question 8

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 breakdown of old red blood cells."
C) "They make lymphocytes for you."
D) "Your lymph nodes help to remove infectious organisms."

Question 9

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? Select all that apply.

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 10

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 to make sure it is regular."
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 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

The nurse is preparing to assess a client newly diagnosed with hyperthyroidism. Which finding should the nurse anticipate?

A) Carotid bruit.
B) Pulse deficit.
C) Hypotension.
D) Delayed capillary refill.

Question 13

The nurse is obtaining a history from an adult female client. Which statement made by the client should the nurse recognize places her at risk for a deep vein thrombosis? Select all that apply.

A) "I spend most of my time sitting at a desk."
B) "I have had a history of a mastectomy."
C) "I have quit smoking 6 months ago."
D) "I have taken oral contraceptives for the last 3 years."
E) "I have 2 glasses of wine every evening."

Question 14

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, and respiratory rate 26 per minute. Which responses by the nurse are appropriate in this situation? Select all that apply.

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?"

Question 15

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

A) Behind the medial malleolus.
B) Lateral wrist.
C) Popliteal fossa.
D) Medial side of the dorsum of the foot.

Question 16

The nurse notes a client has a rusty discoloration over their tibial surface of the skin. Which should the nurse suspect is occurring?

A) Venous disease.
B) Bacterial infection.
C) Trauma to the tissue.
D) Arterial disease.

Question 17

The nurse is reviewing the history of a client. Which findings place the client at risk for damage to the peripheral circulation? Select all that apply.

A) Diabetes.
B) Varicose veins.
C) Blood clots.
D) Asthma.
E) Respiratory disease.

Question 18

The nurse caring for a client post cardiac catheterization is unable to locate pulses in the right distal extremity with the Doppler. Which is the nurse's priority action?

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 19

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? Select all that apply.

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 difficult 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 20

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 21

The nurse is preparing to assess the extremities of a client experiencing right-sided heart failure. Which findings should the nurse anticipate in the lower extremities?

A) Pallor.
B) Sensory loss.
C) Pitting edema.
D) Weak pedal pulses.

Question 22

The nurse is preparing to document the findings associated with a client's peripheral pulses. Which should the nurse include in the documentation? Select all that apply.

A) Rate.
B) Symmetry.
C) Grade.
D) Rhythm.
E) Amplitude.

Question 23

A client with peripheral arterial disease asks why they are experiencing so much pain in their lower extremities. Which information should the nurse be prepared to discuss with the client?

A) Varicose veins.
B) Increased fluid in the extremities.
C) Decreased oxygenation blood flow.
D) Arterial spasms.

Question 24

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 statement made by the client is consistent with the diagnosis? Select all that apply.

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

Question 25

The educator is reviewing the causes of orthostatic hypotension with the nurse. Which information should the educator include? Select all that apply.

A) Medications.
B) Dehydration.
C) Renal disease.
D) Cardiovascular disorder.
E) Endocrine disorder.

Question 26

The nurse is preparing to take a client's blood pressure in a sitting and laying down position. Which results should the nurse anticipate?

A) The blood pressure to be lower when the client is sitting up.
B) The blood pressure to be the same in both positions.
C) The blood pressure to be higher when the client is in a supine position.
D) The blood pressure to be lower when the client is in a supine position.

Question 27

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

A) Calf.
B) Lungs.
C) Popliteal.
D) Ileum.

Question 28

An older client tells the nurse they are experiencing impotence. Which should the nurse be concerned with?

A) Venous disease.
B) Hypertension.
C) Arterial disease.
D) Sexually transmitted infection.

Question 29

The nurse has reviewed the functions of the peripheral vascular system with a client. Which statement made by the client indicates further teaching is needed?

A) "Deliver oxygen and nutrients to tissues of the body."
B) "Produces red blood cells that transport oxygen."
C) "Lymphatic system removes pathogens from the body fluid."
D) "Transports carbon dioxide and waste products from the tissues."