Deck 7: Assessing the Peripheral-Vascular and Lymphatic System

Question 1

While auscultating a patient's neck, the nurse hears a soft, low-pitch, rushing sound. Which conclusion by the nurse is most accurate?

A) Narrowing of the internal or external jugular vein
B) Dilation of the internal or external jugular vein
C) Narrowing of the carotid or temporal artery
D) Dilation of the carotid or temporal artery

Answer 1

Narrowing of the carotid or temporal artery

Question 2

The nurse palpates an older patient's lower legs and notices an indentation of approximately 4 mm left by the fingertips, which disappears in about 10 seconds. How will the nurse document this edema in the medical record?

A) +1
B) +2
C) +3
D) +4

Answer 2

+2

Question 3

The patient had a right mastectomy 2 years ago and now reports pain and swelling of the right arm. Based on this data, which does the nurse suspect?

A) Buerger disease
B) Arterial insufficiency
C) Obstruction of lymph flow
D) Myasthenia gravis

Answer 3

Obstruction of lymph flow

Question 4

When auscultating the patient's blood pressure (BP), what should the nurse do to avoid the auscultatory gap?

A) Take a palpable BP.
B) Inflate the cuff to 30 mm Hg greater than the point where the palpable pulse is obliterated.
C) Inflate the cuff to the point where the palpable pulse is obliterated.
D) Always inflate the cuff above 200 mm Hg pressure.

Question 5

Which assessment findings are expected for a patient diagnosed with Raynaud disease?

A) Streaky redness, tenderness, and warmth along the course of a vein
B) Intermittent pain in calves upon ambulation
C) Gangrene of hands and fingers
D) Intermittent pallor and cyanosis of hands and fingers

Question 6

Which is a role of the peripheral-vascular (PV) system?

A) Transporting oxygen to all body organs
B) Transporting lymph to all body organs
C) Regulating the endocrine system
D) All of the above

Question 7

Intermittent claudication is indicative of which disease process?

A) Arterial insufficiency
B) Raynaud disease
C) Congestive heart failure
D) Venous insufficiency

Question 8

What is the function of lymph nodes?

A) To drain lymph back to right lymphatic duct and thoracic duct
B) To filter microorganisms and foreign substances from lymph
C) To collect fluid from interstitial space and surrounding tissue
D) To secrete thymocytes that help with T-cell differentiation

Question 9

Lymphoid tissue is in greatest abundance at which age?

A) Infancy
B) School age
C) Adolescence
D) Adulthood

Question 10

Which is not a sign of venous insufficiency?

A) Thick skin
B) Poor wound healing
C) Rubor
D) Edema

Question 11

The hospitalized patient complains of pain in the right calf. The nurse notices red streaks along the leg, and it is warm and swollen. Based on this data which condition does the nurse suspect?

A) Arterial insufficiency
B) Venous insufficiency
C) Thrombophlebitis
D) Buerger disease

Question 12

Which factors contribute to increased blood pressure (BP) in older patients from increased PV resistance?

A) Decreased lymph
B) Weakened medial wall
C) Increased wall elasticity
D) Fibrosis of intimal wall

Question 13

Which characteristic should be noted when assessing pulses?

A) Presence of a murmur
B) Split sound
C) Timing in cardiac cycle
D) Amplitude

Question 14

What is the role of the lymphatic system?

A) To move excess tissue fluid in a closed circuit with the cardiovascular system
B) To develop and maintain the immune system
C) To reabsorb fat and fat-soluble substances from the small intestine
D) All of the above

Question 15

Which event during pregnancy causes palmar erythema and spider telangiectasis?

A) Peripheral vasodilation
B) Increased leukocyte count
C) Decreased immunoglobulin G (IgG) concentrations
D) Increased number and size of lymph nodes

Question 16

Before taking a patient's blood pressure (BP), which action by the nurse estimates the patient's systolic pressure?

A) Weighing the patient
B) Inflating the BP cuff 20 mm above the point the radial pulse is occluded
C) Asking the patient about the last BP reading
D) Asking the patient's age

Question 17

Which is the best location for palpation of pulses?

A) Over a bone
B) On soft tissue
C) Under a lymph node
D) On top of a lymph node

Question 18

Which factor contributes to older adults' impaired ability to resist infection and overall lowered immunity?

A) Systemic vascular resistance decreases.
B) Venous elasticity decreases.
C) Lymph nodes become fibrotic and fatty.
D) Thymus shrinks.

Question 19

Which factors can contribute to the formation of edema?

A) High-salt meal
B) Exercise
C) Elevation of extremities
D) Excessive urination

Question 20

What technique is appropriate when auscultating the central and peripheral arteries for bruits?

A) Use the bell of the stethoscope.
B) Use the diaphragm of the stethoscope.
C) Auscultate while the patient inhales deeply.
D) Palpate the radial pulse during auscultation.

Question 21

Which lymph nodes are located in the inguinal area?

A) Pectoral nodes
B) Horizontal nodes
C) Subclavian nodes
D) Suprascapular nodes

Question 22

Which is lymphatic tissue in the thorax that forms antibodies in newborn and developing immune systems?

A) Tonsils
B) Spleen
C) Thymus
D) Epitrochlear nodes

Question 23

Which lymph nodes are located deep in the axilla?

A) Pectoral nodes
B) Horizontal nodes
C) Subclavian nodes
D) Central nodes

Question 24

Which lymph nodes are located in the anterior axillary fold?

A) Pectoral nodes
B) Horizontal nodes
C) Subclavian nodes
D) Supraclavicular nodes

Question 25

Which arterial pulses should be palpated medial to the biceps tendon?

A) Radial pulse
B) Ulnar pulse
C) Femoral pulse
D) Brachial pulse

Question 26

Which lymphatic tissue destroys microorganisms and foreign substances at the beginning of the digestive and respiratory tracts?

A) Tonsils
B) Peyer patches
C) Spleen
D) Thymus

Question 27

Which drains the hands and forearms of lymph?

A) Tonsils
B) Peyer's patches
C) Spleen
D) Epitrochlear nodes
Completion
Complete each statement.

Question 28

Which lymph node is located in the posterior axillary fold?

A) Horizontal node
B) Subclavian node
C) Suprascapular node
D) Central node

Question 29

Edema is documented when there is a difference in leg circumference of 1 cm above the ankle or ________________cm at the calf.

Question 30

Which is lymphatic tissue that filters blood and produces lymphocytes and monocytes?

A) Peyer patches
B) Spleen
C) Thymus
D) Tonsils

Question 31

Which is considered an orthostatic drop in BP?

A) More than 20 mm Hg
B) More than 30 mm Hg
C) More than 40 mm Hg
D) More than 50 mm Hg

Question 32

Which lymph node is located below the clavicle?

A) Horizontal node
B) Subclavian node
C) Suprascapular node
D) Central node

Question 33

A 30-mm systolic or ____________________-mm diastolic increase in blood pressure (BP) may indicate preeclampsia.

Question 34

Which statement is true regarding the lymphatic system?

A) The lymphatic system is able to pump lymph independently of the cardiovascular system.
B) The lymphatic system pumps blood through the cardiovascular system.
C) The lymphatic system carries oxygen to the major organs.
D) The lymphatic system carries unoxygenated blood back to the heart.

Question 35

Which location will the nurse use to assess the posterior tibialis pulse?

A) The dorsum of the foot
B) The back of the knee
C) The apex of the heart
D) The ventral portion of the neck

Question 36

When assessing the central and peripheral arteries for bruits, what sound should normally be heard?

A) No sound
B) A swishing sound
C) S₁ and S₂
D) A murmur

Question 37

Which is described as clusters of non-capsulated lymph tissue found in the small intestines and appendix?

A) Tonsils
B) Peyer patches
C) Thymus
D) Epitrochlear nodes