Ch. 21: Peripheral Vascular & Lymphatic System

Question 1

A function of the venous system includes:

a. holding more blood when blood volume increases
b. conserving fluid and plasma proteins that leak out of the capillaries
c. forming a major part of the immune system that defends the body against disease
d. absorbing lipids from the intestinal tract

Answer 1

a. holding more blood when blood volume increases

Question 2

Which of the following organs aid the lymphatic system?

a. liver, lymph nodes, and stomach
b. pancreas, small intestine, and thymus
c. spleen, tonsils, and thymus
d. pancreas, spleen, and tonsils

Answer 2

c. spleen, tonsils, and thymus

Question 3

Ms. T. has come for a prenatal visit. She reports dependent edema, varicosities in the legs, and hemorrhoids. What is the best response?

a. “If these symptoms persist, we will perform an amniocentesis.”
b. “If these symptoms persist, we will discuss having you hospitalized.”
c. “The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy.”
d. “At this time, the symptoms are a minor inconvenience. You should learn to accept them.”

Answer 3

c. “The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy.”

Question 4

A patient’s pulse with an amplitude of 3+ indicates:

a. Irregular, with 3 premature beats
b. Increased, full
c. Normal
d. Weak

Answer 4

b. Increased, full

Question 5

Inspection of a person’s right hand reveals a red swollen area. To further assess for infection, you would palpate the:

a. cervical node
b. axillary node
c. epitrochlear node
d. inguinal node

Answer 5

c. epitrochlear node

Question 6

To screen for deep vein thrombosis, you would:

a. measure the circumference of the ankle
b. check the temperature with the palm of the hand
c. compress the dorsalis pedis pulse, looking for blood return
d. measure the widest point with a tape measure

Answer 6

d. measure the widest point with a tape measure

Question 7

During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should:

a. proceed with the examination. It is often impossible to palpate this pulse
b. refer the patient to a vascular surgeon for further evaluation
c. schedule the patient for a venogram
d. schedule the patient for an arteriogram

Answer 7

a. proceed with the examination. It is often impossible to palpate this pulse

Question 8

You assess a patient who has 4+ edema of the right leg. What is the best way to document this finding?

a. mild pitting, no perceptible swelling of the leg
b. moderate pitting, indentation subsides rapidly
c. deep pitting, leg looks swollen
d. very deep pitting, indentation lasts a long time

Answer 8

d. very deep pitting, indentation lasts a long time

Question 9

You assess a patient for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and then having the person sit up and dangle the leg, the color should return in:

a. 5 seconds or less
b. 10 seconds or less
c. 15 seconds
d. 30 seconds

Answer 9

b. 10 seconds or less

Question 10

A 54-year-old woman with 5 children has varicose veins of the lower extremities. Her most characteristic sign is:

a. reduced arterial circulation
b. blanching, deathlike appearance of the extremities on elevation
c. loss of hair on feet and toes
d. dilated, tortuous superficial bluish vessels

Answer 10

d. dilated, tortuous superficial bluish vessels

Question 11

Atrophic skin changes that occur with peripheral arterial insufficiency include:

a. thin, shiny skin with loss of hair
b. brown discoloration
c. thick, leathery skin
d. slow-healing blisters on the skin

Answer 11

a. thin, shiny skin with loss of hair

Question 12

Intermittent claudication includes:

a. muscular pain relieved by exercise
b. neurologic pain relieved by exercise
c. muscular pain brought on by exercise
d. neurologic pain brought on by exercise

Answer 12

c. muscular pain brought on by exercise

Question 13

A known risk factor for venous ulcer development is:

a. obesity
b. male gender
c. history of hypertension
d. daily aspirin therapy

Answer 13

a. obesity

Question 14

Arteriosclerosis is caused by:

a. deposition of fatty plaques on the intima of the arteries
b. loss of elasticity of the walls of blood vessels
c. loss of lymphatic tissue that occurs in the aging process
d. progressive enlargement of the intramuscular calf veins

Answer 14

b. loss of elasticity of the walls of blood vessels

Question 15

Raynaud phenomenon occurs

a. when the patient’s extremities are exposed to heat and compression
b. in hands and feet as a result of exposure to cold, vibration, and stress
c. after removal of lymph nodes or damage to lymph nodes and channels
d. as a result of leg cramps due to excessive walking or climbing stair

Answer 15

b. in hands and feet as a result of exposure to cold, vibration, and stress

Question 16

Which of these statements is true regarding the arterial system?

a. arteries are large-diameter vessels
b. the arterial system is a high-pressure system
c. the walls of arteries are thinner than those of veins
d. arteries can expand greatly to accommodate a large blood volume increase

Answer 16

b. the arterial system is a high-pressure system

The pumping heart makes the arterial system a high-pressure system.

Question 17

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.

a. ulnar
b. radial
c. brachial
d. deep palmar

Answer 17

c. brachial

The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

Question 18

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

a. behind the knee
b. over the lateral malleolus
c. in the groove behind the medial malleolus
d. lateral to the extensor tendon of the great toe

Answer 18

d. lateral to the extensor tendon of the great toe

The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. There is no pulse palpated at the lateral malleolus.

Question 19

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg.

a. venous obstruction of
b. claudication due to venous abnormalities in
c. ischemia caused by partial blockage of an artery supplying
d. ischemia caused by complete blockage of an artery supplying

Answer 19

c. ischemia caused by partial blockage of an artery supplying

Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

Question 20

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?

a. intraluminal valves ensure unidirectional flow toward the heart
b. contracting skeletal muscles milk blood distally toward the veins
c. the high-pressure system of the heart helps to facilitate venous return
d. increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart

Answer 20

a. intraluminal valves ensure unidirectional flow toward the heart

Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

Question 21

Which of these veins are responsible for most of the venous return in the arm?

a. deep
b. ulnar
c. subclavian
d. superficial

Answer 21

d. superficial

The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

Question 22

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, “What happens to my circulation when the veins are removed?” The nurse should reply:

a. “Venous insufficiency is a common problem after this type of surgery.”
b. “Oh, we have lots of veins—you won’t even notice that it has been removed.”
c. “You will probably experience decreased circulation after the veins are removed.”
d. “Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation.”

Answer 22

d. “Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation.”

As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation. The other responses are not correct.

Question 23

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?

a. woman in her second month of pregnancy
b. person who has been on bed rest for 4 days
c. person with a 30-year, 1 pack per day smoking history
d. elderly person taking anticoagulant medication

Answer 23

b. person who has been on bed rest for 4 days

At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.

Question 24

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?

a. “Lymph flow is propelled by the contraction of the heart.”
b. “The flow of lymph is slow compared with that of the blood.”
c. “One of the functions of the lymph is to absorb lipids from the biliary tract.”
d. “Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream.”

Answer 24

b. “The flow of lymph is slow compared with that of the blood.”

The flow of lymph is slow compared with that of the blood. Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream.

Question 25

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?

a. assess the patient’s abdomen, and notice any tenderness
b. carefully assess the cervical lymph nodes, and check for any enlargement
c. ask additional history questions regarding any recent ear infections or sore throats
d. examine the patient’s lower arm and hand, and check for the presence of infection or lesions

Answer 25

d. examine the patient’s lower arm and hand, and check for the presence of infection or lesions

The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

Question 26

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?

a. hard and fixed cervical nodes
b. enlarged and tender inguinal nodes
c. bilateral enlargement of the popliteal nodes
d. “Pellet-like” nodes in the supraclavicular region

Answer 26

b. enlarged and tender inguinal nodes

The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

Question 27

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?

a. excessive swelling of the lymph nodes
b. the presence of palpable lymph nodes
c. no nodes palpable because of the immature immune system of a child
d. fewer numbers and a smaller size of lymph nodes compared with those of an adult

Answer 27

b. the presence of palpable lymph nodes

Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

Question 28

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

a. hormonal changes causing vasodilation and a resulting drop in blood pressure
b. progressive atrophy of the intramuscular calf veins, causing venous insufficiency
c. peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
d. narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

Answer 28

c. peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

Question 29

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:

a. claudication
b. sore muscles
c. muscle cramps
d. venous insufficiency

Answer 29

a. claudication

Intermittent claudication feels like a “cramp” and is usually relieved by rest within 2 minutes. The other responses are not correct.

Question 30

A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed “a sore” on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing:

a. pain related to lymphatic abnormalities
b. problems related to arterial insufficiency
c. problems related to venous insufficiency
d. pain related to musculoskeletal abnormalities

Answer 30

b. problems related to arterial insufficiency

Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

Question 31

During an assessment, the nurse uses the “profile sign” to detect:

a. pitting edema
b. early clubbing
c. symmetry of the fingers
d. insufficient capillary refill

Answer 31

b. early clubbing

The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

Question 32

The nurse is performing an assessment on an adult. The adult’s vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next?

a. ask the patient about a past history of frostbite.
b. suspect that the patient has a venous insufficiency problem
c. consider this a delayed capillary refill time and investigate further
d. consider this a normal capillary refill time that requires no further assessment

Answer 32

c. consider this a delayed capillary refill time and investigate further

Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

Question 33

When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?

a. document the finding.
b. auscultate the site for a bruit
c. check for calf pain
d. check capillary refill in the toes

Answer 33

b. auscultate the site for a bruit

If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.

Question 34

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient’s skin is warm and capillary refill time is normal. The nurse should next:

a. check for the presence of claudication
b. refer the individual for further evaluation
c. consider this a normal finding and proceed with the peripheral vascular evaluation
d. ask the patient if he or she has experienced any unusual cramping or tingling in the arm

Answer 34

c. consider this a normal finding and proceed with the peripheral vascular evaluation

It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.

Question 35

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse.

a. normal
b. absent
c. bounding
d. weak, thready

Answer 35

c. bounding

A full, bounding pulse occurs with hyperkinetic states (such as exercise, anxiety, fever), anemia, and hyperthyroidism. Absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease.

Question 36

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?

a. to measure the rate of lymphatic drainage
b. to evaluate the adequacy of capillary patency before venous blood draws
c. to evaluate the adequacy of collateral circulation before cannulating the radial artery
d. to evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

Answer 36

c. to evaluate the adequacy of collateral circulation before cannulating the radial artery

A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.

Question 37

A patient has a positive Homans’ sign. The nurse knows that a positive Homans’ sign may indicate:

a. venous insufficiency
b. deep vein thrombosis
c. severe edema
d. problems with arterial circulation

Answer 37

b. deep vein thrombosis

Calf pain on dorsiflexion of the foot is a positive Homans’ sign, which occurs in about 35% of deep vein thromboses. It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury.

Question 38

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

a. a unilateral cool foot
b. thin, shiny, atrophic skin
c. pallor of the toes and cyanosis of the nail beds
d. a brownish discoloration to the skin of the lower leg

Answer 38

d. a brownish discoloration to the skin of the lower leg

A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

Question 39

The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate?

a. have the patient assume a prone position
b. ask the patient to bend his or her knees to the side in a froglike position
c. press firmly against the bone with the patient in a semi-Fowler position
d. listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person

Answer 39

b. ask the patient to bend his or her knees to the side in a froglike position

To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

Question 40

When auscultating over a patient’s femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:

a. bruits are often associated with venous disease
b. bruits occur in the presence of lymphadenopathy
c. hypermetabolic states will cause bruits in the femoral arteries
d. bruits occur with turbulent blood flow, indicating partial occlusion

Answer 40

d. bruits occur with turbulent blood flow, indicating partial occlusion

A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

Question 41

How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient?

a. 1+/0-4+
b. 3+/0-4+
c. 4+/0-4+
d. brawny edema

Answer 41

a. 1+/0-4+

If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

Question 42

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:

a. nonpitting, hard edema occurs with lymphatic obstruction
b. alterations in arterial function will cause this edema
c. phlebitis of a superficial vein will cause bilateral edema
d. long-standing arterial obstruction will cause pitting edema

Answer 42

a. nonpitting, hard edema occurs with lymphatic obstruction

Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).

Question 43

When assessing a patient’s pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:

a. alternans
b. bisferiens
c. bigeminus
d. paradoxus

Answer 43

d. paradoxus

In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger amplitude with expiration. It is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

Question 44

The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan’s sign. The nurse should:

a. reevaluate the patient in a few hours
b. consider this a normal finding for a bedridden patient
c. seek emergency referral because of the risk of pulmonary embolism
d. ask the patient to raise his leg off of the bed and check for pain on elevation

Answer 44

c. seek emergency referral because of the risk of pulmonary embolism

Increased warmth, swelling, redness, and tenderness in the lower extremities require emergency referral because of the risk of pulmonary embolism from a deep vein thrombosis.

Question 45

During an assessment the nurse has elevated a patient’s legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be:

a. marked elevational pallor
b. venous filling within 15 seconds
c. no change in coloration of the skin
d. color returning to the feet within 20 seconds of assuming a sitting position

Answer 45

b. venous filling within 15 seconds

In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as delayed venous filling occurs with arterial insufficiency.

Question 46

During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel “heavy in the calf” and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings?

a. deep vein thrombophlebitis
b. varicose veins
c. lymphedema
d. Raynaud’s phenomenon

Answer 46

b. varicose veins

Superficial varicose veins are caused by incompetent distant valves on veins, which results in reflux of blood and producing dilated, tortuous veins. They are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are seen on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See Table 20-2 for descriptions of Raynaud’s phenomenon and lymphedema.

Question 47

The nurse is preparing to perform a manual compression test on a patient. Which of these statements is true about this procedure?

a. rapid filling of the veins indicates incompetent veins
b. competent valves in the veins will transmit a wave to the distal fingers
c. a palpable wave transmission occurs when the valves are incompetent
d. the test assesses whether the valves of varicosity are competent when the person is in the supine position

Answer 47

c. a palpable wave transmission occurs when the valves are incompetent

With the manual compression test, a palpable wave transmission occurs when the valves are incompetent. Competent veins will prevent a wave transmission and the nurse’s distal (lower) fingers will feel no change. The test is performed while the patient is standing.

Question 48

During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?

a. venous stasis
b. lymphedema
c. arteriosclerosis
d. deep vein thrombosis

Answer 48

b. lymphedema

Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and it can impede drainage of lymph. The other responses are not correct.

Question 49

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true?

a. normal ABI indices are from 0.50 to 1.0
b. the normal ankle pressure is slightly lower than the brachial pressure
c. the ABI is a reliable measurement of peripheral vascular disease in diabetic individuals
d. an ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication

Answer 49

d. an ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication

Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a falsely high ankle pressure.

Question 50

The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His medical history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this situation?

a. enlarged, warm, tender nodes
b. lymphadenopathy of the cervical nodes
c. palpable firm, small, shotty, mobile, nontender lymph nodes
d. firm, rubbery, large nodes, somewhat fixed to the underlying tissue

Answer 50

c. palpable firm, small, shotty, mobile, nontender lymph nodes

Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.

Question 51

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?

a. low humming sound
b. regular “lub, dub” pattern
c. swishing, whooshing sound
d. steady, even, flowing sound

Answer 51

c. swishing, whooshing sound

When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

Question 52

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct?

a. “Easily palpable, pounds under the fingertips.”
b. “Greater than normal force, then collapses suddenly.”
c. “Hard to palpate, may fade in and out, easily obliterated by pressure.”
d. “Rhythm is regular, but force varies with alternating beats of large and small amplitude.”

Answer 52

c. “Hard to palpate, may fade in and out, easily obliterated by pressure.”

A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

Question 53

peripheral arterial disease.

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:

a. lymphedema
b. Raynaud’s disease
c. deep vein thrombosis
d. chronic arterial insufficiency

Answer 53

b. Raynaud’s disease

The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud’s disease.

Question 54

During a routine office visit, a patient takes off his shoes and shows the nurse “this awful sore that won’t heal.” On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:

a. varicosities
b. a venous stasis ulcer
c. an arterial ischemic ulcer
d. deep vein thrombophlebitis

Answer 54

c. an arterial ischemic ulcer

Arterial ischemic ulcers occur at toes, metatarsal heads, heels, and lateral ankle, and they are characterized by a pale ischemic base, well-defined edges, and no bleeding.

Question 55

The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what type of pulse?

a. bounding
b. normal
c. weak
d. absent

Answer 55

b. normal

When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

Question 56

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient’s lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply.

a. intense, sharp pain, with the deep muscle tender to touch
b. aching, tired pain, with a feeling of fullness
c. pain is worse at the end of the day
d. sudden onset
e. warm, red, and swollen calf
f. pain that is relieved with elevation of leg

Answer 56

a. intense, sharp pain, with the deep muscle tender to touch
d. sudden onset
e. warm, red, and swollen calf

Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.

Question 57

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply.

a. the patient has a history of diabetes and cigarette smoking
b. the patient’s skin is pale and cool
c. the patient’s ankles have two small, weeping ulcers
d. the patient works long hours sitting at a computer desk
e. the patient states that the pain gets worse when walking
f. the patient states that the pain is worse at the end of the day

Answer 57

a. the patient has a history of diabetes and cigarette smoking
b. the patient’s skin is pale and cool
e. the patient states that the pain gets worse when walking

Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset, with exertion, and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems.