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?

Accepted Answer

The symptoms described by the client are characteristic of Raynaud disease, which involves episodes of decreased blood flow to the fingers and toes, causing them to turn white and then red.

Question 2

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

Accepted Answer

B,E

Question 3

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

Accepted Answer

Chronic bronchitis can lead to decreased oxygen levels in the blood, which can cause cyanosis, a bluish discoloration of the skin, including under the nails. This makes "How long have your nails been a bluish color?" the most relevant question.

Question 4

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

Accepted Answer

Bulging veins near the surface of the skin are expected due to the increased blood flow through the arteriovenous fistula, which is created to facilitate dialysis.

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?

Accepted Answer

A difference of 15 mmHg or more in systolic blood pressure readings between arms can indicate a unilateral arterial obstruction, such as might occur with peripheral artery disease or aortic dissection, rather than inaccurate technique, anxiety, or 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?

Accepted Answer

Asking about surgical procedures is most appropriate because unilateral swelling (swelling in one arm and not the other) could be related to surgical removal of lymph nodes or other procedures that might affect lymphatic drainage or blood flow, leading to edema in the affected 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.

Accepted Answer

The answer of The nurse is teaching a client what...

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?

Accepted Answer

Lymph nodes play a crucial role in the immune system by filtering lymph fluid and trapping bacteria, viruses, and other foreign substances, which are then destroyed by specialized white blood cells called lymphocytes.

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.

Accepted Answer

Varicose veins can be influenced by genetic predisposition, occupations that require prolonged standing (such as a hair stylist), pregnancy, and obesity. These factors can increase the pressure in the leg veins or weaken vein walls, leading to varicose veins. Ethnicity, such as being of Japanese descent, is not specifically identified as a risk factor for varicose veins.

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?

Accepted Answer

Feeling for the pulse before taking blood pressure helps in estimating the systolic pressure, which can lead to a more accurate reading by avoiding over-inflation of the cuff.

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

The characteristics of the ulcer suggest a possible vascular origin, making the assessment of peripheral pulses crucial to determine blood flow and vascular health in the affected limb.

Question 12

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

Accepted Answer

Carotid bruit can be associated with hyperthyroidism due to increased blood flow through the arteries.

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.

Accepted Answer

- Prolonged sitting, such as spending most of the time at a desk, can lead to decreased circulation and increase the risk for deep vein thrombosis (DVT) due to the lack of movement and blood pooling in the legs.- The use of oral contraceptives is known to increase the risk of DVT due to the hormonal changes they cause, which can affect blood clotting mechanisms.

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.

Accepted Answer

The answer of While performing a focused interview with a...

Question 15

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 dorsalis pedis pulse is located on the top of the foot, specifically on the medial side of the dorsum of the foot. This pulse point is used to assess circulation to 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?

Accepted Answer

Rusty discoloration over the tibial surface of the skin is often associated with venous disease, indicating issues with venous circulation and possibly venous stasis, which can lead to skin changes including discoloration.

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.

Accepted Answer

The answer of The nurse is reviewing the history of...

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?

Accepted Answer

The nurse should assess for the client's right popliteal pulse to determine if there is blood flow further up the leg, which can help identify the location of any potential blockage or issue.

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.

Accepted Answer

The answer of The nurse educator is teaching a group...

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?

Accepted Answer

Impaired lymphatic drainage is the most probable cause of the edema in the client's left arm, especially given the history of a left mastectomy. Mastectomy, particularly when it involves lymph node removal, can disrupt normal lymphatic drainage and lead to lymphedema in the affected arm.

Quiz 19: Peripheral Vascular System