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?

Accepted Answer

The soft, low-pitch, rushing sound heard while auscultating the patient's neck is indicative of a bruit, which is caused by turbulent blood flow. This is most commonly associated with the narrowing (stenosis) of arteries, such as the carotid or temporal artery, rather than veins.

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?

Accepted Answer

The nurse will document this finding as +2 edema. In medical terms, +2 edema indicates a moderate pitting edema, where an indentation of about 4 mm is left by the fingertips and disappears in about 10-15 seconds.

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?

Accepted Answer

The symptoms of pain and swelling in the arm following a mastectomy are indicative of lymphedema, which is caused by obstruction of lymph flow. This can occur after mastectomy due to removal of lymph nodes or damage to lymphatic vessels.

Question 4

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

Accepted Answer

Inflating the cuff to 30 mm Hg greater than the point where the palpable pulse is obliterated helps to ensure that the auscultatory gap (a temporary disappearance of sounds normally heard over the brachial artery when the blood pressure cuff is deflated) is not missed. This technique allows the nurse to accurately capture the systolic pressure without being misled by the auscultatory gap.

Question 5

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

Accepted Answer

Raynaud disease is characterized by episodic vasospastic attacks that cause the extremities, particularly the fingers, to turn white (pallor) and then blue (cyanosis) due to lack of blood flow and subsequent return of blood flow.

Question 6

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

Accepted Answer

The peripheral-vascular (PV) system, which includes arteries, veins, and capillaries, plays a crucial role in transporting oxygen (and nutrients) to all body organs, as well as removing waste products from them.

Question 7

Intermittent claudication is indicative of which disease process?

Accepted Answer

Intermittent claudication is a symptom of peripheral artery disease (PAD), which is caused by arterial insufficiency. It is characterized by muscle pain on mild exertion (such as walking) that disappears with rest, due to inadequate blood flow to the muscles.

Question 8

What is the function of lymph nodes?

Accepted Answer

Lymph nodes function primarily to filter microorganisms and foreign substances from lymph, which helps protect the body against infection and disease.

Question 9

Lymphoid tissue is in greatest abundance at which age?

Accepted Answer

Lymphoid tissue is most abundant during school age, as the immune system is developing and preparing to protect the body against pathogens.

Question 10

Which is not a sign of venous insufficiency?

Accepted Answer

Rubor, or redness of the skin, is more commonly associated with arterial insufficiency rather than venous insufficiency. Venous insufficiency typically presents with symptoms such as thick skin, poor wound healing, and 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?

Accepted Answer

The symptoms described, such as pain in the calf, red streaks along the leg, warmth, and swelling, are indicative of thrombophlebitis. This condition involves inflammation of a vein in conjunction with the formation of a blood clot (thrombus).

Question 12

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

Accepted Answer

Fibrosis of the intimal wall increases peripheral vascular resistance, which in turn increases blood pressure.

Question 13

Which characteristic should be noted when assessing pulses?

Accepted Answer

Amplitude is a characteristic of pulses that should be noted, as it reflects the strength or intensity of the pulse.

Question 14

What is the role of the lymphatic system?

Accepted Answer

The lymphatic system has multiple roles including moving excess tissue fluid back into the bloodstream, developing and maintaining the body's immune system, and reabsorbing fats and fat-soluble substances from the digestive system.

Question 15

Which event during pregnancy causes palmar erythema and spider telangiectasis?

Accepted Answer

Peripheral vasodilation during pregnancy increases blood flow to the skin, which can cause palmar erythema and spider telangiectasis.

Question 16

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

Accepted Answer

Inflating the BP cuff 20 mm Hg above the point where the radial pulse disappears helps to estimate the systolic pressure. This technique ensures that the cuff is inflated sufficiently to occlude arterial blood flow, allowing for an accurate measurement of the point at which blood flow resumes, which corresponds to systolic pressure.

Question 17

Which is the best location for palpation of pulses?

Accepted Answer

Palpating pulses over a bone provides a firm surface against which the artery can be compressed, making the pulse more palpable. Soft tissue, lymph nodes, or on top of a lymph node do not provide the necessary resistance for effective palpation.

Question 18

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

Accepted Answer

As people age, their lymph nodes can become fibrotic and fatty, which impairs their ability to produce and circulate lymphocytes, contributing to a weakened immune response.

Question 19

Which factors can contribute to the formation of edema?

Accepted Answer

A high-salt meal can lead to water retention, increasing blood volume and pressure, which can contribute to the formation of edema.

Question 20

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

Accepted Answer

The bell of the stethoscope is more sensitive to the low-frequency sounds typical of bruits, making it the appropriate choice for auscultating arteries.

Quiz 7: Assessing the Peripheral-Vascular and Lymphatic System