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?

Accepted Answer

B,C,D

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?

Accepted Answer

A difference of 15 mmHg in systolic blood pressure readings between arms is significant and can indicate unilateral arterial obstruction, such as a blocked or narrowed artery. Inaccurate technique would likely result in inconsistent readings or errors in measurement. Anxiety or shock may cause changes in blood pressure, but would not consistently affect only one arm.

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?

Accepted Answer

The Allen test is typically used to determine the patency of the ulnar and radial arteries. This test involves compressing both the ulnar and radial arteries while the client makes a fist. The client is then asked to open their hand while the ulnar artery is released to see if blood flow has resumed, indicating patency of the artery.

Question 4

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

Accepted Answer

Ankle and feet swelling and bleeding ulcer are signs of venous insufficiency.

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?

Accepted Answer

Feeling for the pulse prior to taking blood pressure helps to ensure accuracy of the reading. This is because the pulse provides an estimate of the client's systolic blood pressure, which is helpful in selecting the appropriate size cuff and determining the appropriate inflation level. This can lead to a more accurate blood pressure reading. Option A is not the most appropriate response as it does not answer the client's question. Option B is not appropriate as it could cause unnecessary anxiety for the client. Option D is not correct as feeling for the pulse is not the best way to determine 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?

Accepted Answer

The client's history of left mastectomy suggests that the lymphatic drainage in the left arm may be impaired, leading to edema. Bilateral ankle edema is a common symptom in clients with CHF, indicating right-sided heart failure. Noncompliance with medications or excessive sodium intake may contribute to fluid retention, but these are not the most probable causes for the edema in the left arm.

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?

Accepted Answer

The answer of While assessing a client with a laceration...

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?

Accepted Answer

B) Palpating the carotid pulses one side at a time prevents the risk of compromising blood flow to the brain, which could occur if both were palpated simultaneously. D) Inspecting the arms to ensure they are close to the same size helps identify potential swelling or abnormalities related to the peripheral vascular system. E) Observing the extremities for normal and symmetrical hair distribution, as well as ensuring the skin is clean and free of lesions, are important aspects of assessing the peripheral vascular system for signs of circulation issues or other abnormalities.

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?

Accepted Answer

Unilateral swelling, such as 2+ pitting edema in one arm but not the other, can indicate a localized issue rather than a systemic problem. Asking about surgical procedures is appropriate because surgeries, especially those involving lymph node removal or damage to the lymphatic system, can lead to lymphedema, which might present as swelling in one 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?

Accepted Answer

The answer of The nurse is preparing to assess the...

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?

Accepted Answer

Checking for peripheral pulses would provide information on the blood flow to the client's lower extremities and may indicate the presence of peripheral artery disease or other circulatory issues that could contribute to the development of the ulcer.

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?

Accepted Answer

Lymph nodes are part of the lymphatic system and play a crucial role in the body's immune response by filtering and trapping infectious organisms, such as bacteria and viruses, and initiating an immune response to combat them. They also help to remove cellular waste and extra fluid from tissues. The other options are not correct descriptions of the function of lymph nodes.

Question 13

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

Accepted Answer

The answer of The nurse is educating a client about...

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?

Accepted Answer

Varicose veins can be hereditary (A), and occupations that require prolonged standing, like hair styling, increase risk (C). Pregnancy (D) and obesity (E) are also known risk factors.

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?

Accepted Answer

The answer of The nurse is completing an assessment on...

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?

Accepted Answer

During a peripheral vascular assessment, the nurse should assess the temperature and the presence of hair on the feet and toes to determine blood flow. However, the Trendelenburg's test is performed to assess arterial blood flow in the legs, and the Allen's test is used to assess collateral circulation in the hand. The nurse should never test sensation by injecting the client.

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?

Accepted Answer

The Trendelenburg test is used to assess the competence of the venous valves in the superficial and deep venous systems. Rapid filling of superficial veins during this test indicates that the valves in the veins are not functioning properly, allowing blood to flow backward, which is consistent with valve incompetence.

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?

Accepted Answer

Taking a blood pressure cuff, Doppler, and stethoscope into the client's room for the assessment is appropriate for assessing the client's peripheral vascular system. 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 is not appropriate as the client is potentially in distress and needs immediate intervention. Requesting the client remove all undergarments prior to putting the gown is not necessary for assessing the peripheral vascular system. Assessing pedal pulses over the client's socks is not accurate and the socks should be removed prior to assessing peripheral pulses.

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?

Accepted Answer

Chronic bronchitis can lead to hypoxia (low oxygen levels in the body) which can cause cyanosis (bluish discoloration of the skin and nails) due to inadequate oxygenation. Therefore, the client's statement that their nails always look a little bluish is consistent with their diagnosis.

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?

Accepted Answer

The client's symptoms of whitish discoloration followed by redness are classic indicators of Raynaud disease, which is a disorder that causes spasms in the blood vessels of the extremities, resulting in reduced blood flow and subsequent color changes. The other disorders listed do not typically present with these specific symptoms.

Quiz 20: Peripheral Vascular System