Week #5: Peripheral Vascular & Lymphatic

Question 1

The 6-Ps of arterial occlusion include which of the following? Select all that apply.
a) Pulselessness
b) Pain
c) Paresthesia
d) Pilonidal
e) Pilocarpine
f) Pallor

Answer 1

a) Pulselessness
b) Pain
c) Paresthesia
f) Pallor

Question 2

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this?
a) 4+ pitting edema
b) 3+ pitting edema
c) 2+ pitting edema
d) 1+ pitting edema

Answer 2

b) 3+ pitting edema

Question 3

A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what?
a) Deep vein thrombosis (DVT)
b) Varicose vein
c) Lymphedema
d) Pulmonary embolism (PE)

Answer 3

a) Deep vein thrombosis (DVT)

Question 4

What pulse is located in the groove between the medial malleolus and the Achilles tendon?
a) Dorsalis pedis
b) Posterior tibial
c) Popliteal
d) Femoral

Answer 4

b) Posterior tibial

Question 5

During the assessment, the nurse identifies warm thick skin that is swollen and reddish-blue. The nurse also notes an ulcer at the ankle that the client described pain at the ulcer site as achy. The nurse suspects the client may have what?
a) Intermittent claudication
b) Hypertrophic changes
c) Arterial insufficiency
d) Venous insufficiency

Answer 5

d) Venous insufficiency

Question 6

When assessing the lower extremities, its critical that the examiner:
a) Starts at the femoral area
b) Evaluates the venous system and then the arterial system
c) Starts at the feet
d) Compares side to side

Answer 6

d) Compares side to side

Question 7

The nurse assessing the clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer?
a) The extremity has an easily palpable, strong pulse
b) The borders are irregular
c) The ulcer is superficial and pink
d) The ulcer is necrotic

Answer 7

d) The ulcer is necrotic

Question 8

Maintaining fluid balance is one function of the lymphatic system.
a) True
b) False

Answer 8

a) True

Question 9

One extremity cooler than the other indicates arterial insufficiency.
a) True
b) False

Answer 9

a) True

Question 10

A client comes to the clinic reporting pain in her legs while walking. The client states the pain goes away when resting. The nurse suspects the client is experiencing what?
a) Deep vein thrombosis
b) Pulmonary embolism
c) Intermittent claudication
d) Varicose veins

Answer 10

c) Intermittent claudication

Question 11

Brownish discoloration in the “gaiter” or ankle area.
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 11

b) Chronic venous insufficiency (CVI)

Question 12

Ulcer borders are regular
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 12

a) Peripheral arterial disease (PAD)

Question 13

Edema in extremity
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 13

b) Chronic venous insufficiency (CVI)

Question 14

Pain is relieved when extremity is elevated
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 14

b) Chronic venous insufficiency (CVI)

Question 15

Pain is relieved when extremity is in the dependent position
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 15

a) Peripheral arterial disease (PAD)

Question 16

Claudication is often seen
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 16

a) Peripheral arterial disease (PAD)

Question 17

Extremity normal in size or with apparent atrophy
a) Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 17

a) Peripheral arterial disease (PAD)

Question 18

Ulcer borders are irregular
a)Peripheral arterial disease (PAD)
b) Chronic venous insufficiency (CVI)

Answer 18

b) Chronic venous insufficiency (CVI)

Question 19

Pulse found halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament.

Answer 19

Femoral

Question 20

Pulse best palpated with your fingers braced on the knee, circling your hands around the back of the knee and pressing against the lower edge of the femur. Might be felt immediately lateral to the medial tendon (often difficult to locate).

Answer 20

Popliteal

Question 21

Pulse found approximately at the inner third of the antecubital fossa when the palm is held upward.

Answer 21

Brachial

Question 22

Pulse found in the groove between the medial malleolus and Achilles tendon.

Answer 22

Posterior tibial

Question 23

Pulse found approximately halfway up the foot immediately lateral to the extensor tendon of the great toe.

Answer 23

Dorsalis Pedis

Question 24

Pulse found on the thumb side of the forearm at the wrist.

Answer 24

Radial

Question 25

Monthly assessment of the feet is essential for patients with peripheral arterial disease (PAD).
a) True
b) False

Answer 25

b) False

Question 26

The more distal a vein is, the lower the number of valves, because the pull of gravity is stronger.
a) True
b) False

Answer 26

b) False

Question 27

Arterioles have more smooth muscle, and it is here that blood pressure is controlled.
a) True
b) False

Answer 27

a) True

Question 28

Arteriosclerosis is seen more in the older adult.
a) True
b) False

Answer 28

a) True

Question 29

Venous insufficiency may result in dilated and tortuous veins.
a) True
b) False

Answer 29

a) True

Question 30

The _____________ maintains fluid and protein balance and functions with the immune system to fight infection.

Answer 30

Lymphatic system

Question 31

If untreated, ______________ may progress and result in irreversible tissue enlargement.

Answer 31

Fibrosis

Question 32

___________________, diabetes, and hyperlipidemia are cardiovascular risk factors with strong genetic components.

Answer 32

Hypertension

Question 33

A blood clot that travels from the legs to the lungs is called a __________________.

Answer 33

Venous Thromboembolism (VTE)

Question 34

The serum ___________ is assessed in the patient with a possible DVT.

Answer 34

D-dimer

Question 35

Chronic venous insufficiency, deep vein thrombosis, and lymphedema result in ______________.

Answer 35

Edema

Question 36

What are the 7-P’s of peripheral artery disease?

Answer 36

1. Pain
2. Pallor
3. Polar
4. Paresthesia
5. Pulselessness
6. Paralysis
7. Perfusion

Question 37

What are 3 signs of a DVT?

Answer 37

Pain, edema, and warmth of an extremity

Question 38

List the scale for edema and how you would classify edema in each.

Answer 38

+1: slight pitting, 2-mm depression
+2: increased pitting, 4-mm depression
+3: deeper pitting, 6-mm depression; obvious edema of extremity
+4: severe pitting, 8-mm depression; extremity appears very edematous

Question 39

Pain brought on by exertion and relieved by rest

Answer 39

Intermittent Claudication

Question 40

Name 3 nursing diagnoses associated with the peripheral vascular system:

Answer 40

1. Ineffective peripheral tissue perfusion
2. Risk for impaired peripheral neurovascular function
3. Activity intolerance

Question 41

What is the normal ankle-brachial index (ABI) range?

Answer 41

1-1.40: Normal
0.91-0.99: Borderline
Less than 0.90: Abnormal
Greater than 1.40: Noncompressible arteries