Chapter 20

Question 1

what is the largest vessel in the system?

Answer 1

aorta

Question 2

how would you assess peripheral perfusion

Answer 2

evaluate peripheral pulses, color, clubbing, capillary refill, skin temperature, edema, ulcerations, hair distribution

Question 3

how do you grade peripheral pulses

Answer 3

0 = absent
1+ = weak, thready
2+ = normal
3+ = full, increased
4+ = bounding

Question 4

what is the CMS check?

Answer 4

C= circulation
M= motor function- neuro function
S= sensation- neuro function

Question 5

describe an arterial ulcer

Answer 5

found on heels, toes, bony prominences, metatarsals, trauma points
- dry pale gray or yellow base, may be necrotic
- regular border, well demarcated
- surrounding tissue is pale, cooler than other skin areas
- claudication, pain at rest, continuous pain that worsens with elevation
pulses may be absent or diminished

Question 6

describe a venous ulcer

Answer 6

found around the ankle and on the lower third of the leg

• generally shallow, but may be deep; pink with moist ucler bed, may have copious drainage
• irregular border
• surrounding tissue may be darkened in color in areas associated with walking, temp may be greater than other skin areas, edema,
• pain is aching, throbbing, heaviness, superficial stinging when the ulcer is exposed to air
• pulses are usually present but may be difficult to palpate

Question 7

lymph nodes are named for

Answer 7

their anatomical location

Question 8

an enlarged node indicates

Answer 8

inflammation “upstream” from it