Chapter 18 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 18

Question 1

Type: HOTSPOT

The nurse is preparing to assess the clients dorsalis pedis pulse. Draw an arrow to where this pulse can be palpated on the following figure.

Screen Shot 2015-09-24 at 12.26.44 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.1: Identify the anatomy and physiology of the peripheral vascular and lymphatic systems.

Question 2

Type: MCSA

A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. The nurse would respond with which of the following statements?

1. Your lymph nodes filter blood for your body.

2. They are responsible for the break down of old red blood cells.

3. They make lymphocytes for you.

4. Your lymph nodes help to remove infectious organisms.

Correct Answer: 4

Rationale 1: Lymph nodes actually filter lymph fluid before returning it to the clients blood.

Rationale 2: The liver is responsible for breaking down old red blood cells.

Rationale 3: Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood.

Rationale 4: This statement is accurate. The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream.

Global Rationale: The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream. The liver is responsible for breaking down old red blood cells. Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18.1: Identify the anatomy and physiology of the peripheral vascular and lymphatic systems.

Question 3

Type: MCMA

The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which of the following statements by the client are associated with risk factors for varicose veins?

Standard Text: Select all that apply.

1. My mother had big veins on her legs from the time I was little.

2. My father is of Japanese descent.

3. Im a hair stylist.

4. I was pregnant once and have a son.

5. I know I weigh a lot more than I should.

Correct Answer: 1,3,5

Rationale 1: My mother had big veins on her legs from the time I was little. A client who has a family history of varicose veins has an increased risk for developing them.

Rationale 2: My father is of Japanese descent. Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins.

Rationale 3: Im a hair stylist. Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins.

Rationale 4: I was pregnant once and have a son. People who have been pregnant multiple times have an increased risk for developing varicose veins.

Rationale 5: I know I weigh a lot more than I should. People who are obese have an increased risk for developing varicose veins.

Global Rationale: A client who has a family history of varicose veins has an increased risk for developing them. Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins. Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins. People who have been pregnant multiple times have an increased risk for developing varicose veins. People who are obese have an increased risk for developing varicose veins.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.2: Develop questions that guide the focused interview.

Question 4

Type: MCMA

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, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which of the following are appropriate responses by the nurse?

Standard Text: Select all that apply.

1. Im going to take your temperature now.

2. Have you ever experienced chest pain?

3. Are you feeling any anxiety right now?

4. Are you experiencing any pain at this time?

5. Have you ever been diagnosed with hypothyroidism?

Correct Answer: 2,3,4

Rationale 1: Im going to take your temperature now. It will be appropriate to assess the clients temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety.

Rationale 2: Have you ever experienced chest pain? The clients actions may indicate that the client is experiencing pain. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview.

Rationale 3: Are you feeling any anxiety right now? The clients actions are consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate.

Rationale 4: Are you experiencing any pain at this time? The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview.

Rationale 5: Have you ever been diagnosed with hypothyroidism? The clients vital signs and actions are more likely associated with hyperthyroidism.

Global Rationale: It will be appropriate to assess the clients temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. The clients actions may indicate that the client is experiencing pain. The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. The clients actions are also consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. The clients vital signs and actions are more likely associated with hyperthyroidism.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.2: Develop questions that guide the focused interview.

Question 5

Type: MCMA

The student nurse is performing an assessment of the clients peripheral vascular system with the experienced nurses guidance. Which of the following actions by the student nurse indicate that the student nurse requires further education?

Standard Text: Select all that apply.

1. The student nurse continues to assess the client while the client is in a flat, supine position. The clients respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips.

2. The student nurse requests that the client remove all undergarments prior to putting the gown.

3. The client left her socks on and the student nurse assesses the clients pedal pulses over the socks.

4. The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination.

5. The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the clients room for this assessment.

Correct Answer: 1,2,3,4

Rationale 1: The student nurse continues to assess the client while the client is in a flat, supine position. The clients respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips. The student nurse should pay careful attention to how well the client tolerates certain positions during the assessment. At this point, the student nurse should sit the client up to allow the client to breathe better.

Rationale 2: The student nurse requests that the client remove all undergarments prior to putting the gown . The client can leave on undergarments for this assessment.

Rationale 3: The client left her socks on and the student nurse assesses the clients pedal pulses over the socks. Socks should be removed prior to assessing the clients feet. Pulses, skin temperature, skin color, quality of sensation, and capillary refill should be assessed and this would be extremely difficult to assess while the clients socks are on her feet.

Rationale 4: The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination. The client should take off her jewelry. Pulses may difficult to palpate around bracelets.

Rationale 5: The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the clients room for this assessment. These pieces of equipment are required to perform this assessment.

Global Rationale: The student nurse must pay attention to how well the client tolerates the various positions during the assessment. The client needs to remove only socks and shoes prior to putting on the gown. The socks must be removed to accurately assess the peripheral vascular system. The client should take off her jewelry prior to the assessment. It is appropriate to bring these pieces of equipment for the assessment.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.3: Explain client preparation for assessment of the peripheral vascular system.

Question 6

Type: MCSA

The nursing student is learning about the appropriate method to use when assessing a clients blood pressure. The student nurse asks the nursing instructor why it is necessary to palpate the systolic pressure prior to the procedure. Which of the following is the nursing instructors best response?

1. You can document this value if you cannot hear the blood pressure well.

2. This needs to be done only when the client is developing clinical manifestations associated with shock.

3. You are more likely to get an accurate reading when you do it this way.

4. It is the best way to determine an arterial obstruction.

Correct Answer: 3

Rationale 1: It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the clients blood pressure.

Rationale 2: When a client is developing clinical manifestations associated with shock, his blood pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure for all clients regardless of their diagnoses.

Rationale 3: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure assessment that can occur with an ausculatory gap, or space in which beats are not heard, during this assessment.

Rationale 4: This can be assessed by measuring the difference between the blood pressures in the arms. A difference of 10 mm Hg or more between the arms may indicate an obstruction of arterial flow to one arm.

Global Rationale: Assessing the palpable systolic pressure helps to avoid inaccuracy in blood pressure assessment that can occur with an ausculatory gap, or space in which beats are not heard, during this assessment. It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the clients blood pressure. When a client is developing clinical manifestations associated with shock, his blood pressure is more likely to be lower than normal. The nurse should palpate the systolic pressure for all clients regardless of their diagnoses. Arterial obstruction can be assessed by measuring the difference between the blood pressures in the arms. A difference of 10 mm Hg or more between the arms may indicate an obstruction of arterial flow to one arm.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral vascular system.

Question 7

Type: MCMA

The student nurse is preparing to perform an assessment of the clients peripheral vascular system. The experienced nurse asks the student nurse questions to ensure the student nurse has prepared adequately. Which of the following statements by the student nurse indicate that further education is required?

Standard Text: Select all that apply.

1. I need to take a blood pressure only in the clients right arm.

2. The best way to assess the carotid pulses is palpate one side and then the other.

3. It will be easier to assess the clients carotid pulses if the client is obese.

4. I should inspect the arms to ensure that they are close to the same size.

5. I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions.

Correct Answer: 1,3

Rationale 1: I need to take a blood pressure only in the clients right arm. A thorough peripheral vascular assessment includes blood pressure measurements taken in both arms and both legs.

Rationale 2: The best way to assess the carotid pulses is palpate one side and then the other. The carotid pulses should not be palpated at the same time because it may cause the client to faint or pass out due to lack of blood flow to the brain.

Rationale 3: It will be easier to assess the clients carotid pulses if the client is obese. It is much easier to assess the clients carotid pulses when the client has a long, thin neck.

Rationale 4: I should inspect the arms to ensure that they are close to the same size. The arms should be compared to each other to ensure that there is not a lymphatic problem that has developed that would result in edema.

Rationale 5: I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions. The skin on the extremities should be clean, dry, and intact. The clients pattern of hair distribution should be evaluated to determine if there is adequate arterial circulation.

Global Rationale: The student nurse should take the clients blood pressure in both arms and both legs. It will be more difficult to assess the clients carotid pulses if the client is obese or has a short neck. The best way to palpate the clients carotid pulses is separately and not simultaneously. The student nurse should ensure that both arms are equal in size. The student nurse should thoroughly assess the clients extremities.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral vascular system.

Question 8

Type: MCMA

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 of the following statements by the nurse are unexpected?

Standard Text: Select all that apply.

1. I am feeling your feet to see how warm they are.

2. I am looking for hair on your toes.

3. I am going to perform the Trendelenburgs test to see how well the radial and ulnar arteries are supplying blood to your hand.

4. I am going to test your ability to feel sensations by giving you an injection.

5. I am going to perform the Allens test to see if you have any varicose veins.

Correct Answer: 3,4,5

Rationale 1: I am feeling your feet to see how warm they are. Warmth felt at the distal portions of the extremities indicate that the client is receiving an adequate amount of arterial blood flow to those areas.

Rationale 2: I am looking for hair on your toes. Hair growth on the clients toes indicates that the client is receiving an adequate amount of arterial blood flow to the toes. This is especially helpful when the client routinely shaves the hair from the legs.

Rationale 3: I am going to perform the Trendelenburgs test to see how well the radial and ulnar arteries are supplying blood to your hand. The Trendelenburgs test is used to determine varicose veins.

Rationale 4: I am going to test your ability to feel sensations by giving you an injection. The nurse should assess the clients ability to feel sensations by using the sharp and dull ends of a safety pin. An adequate ability to feel sensations indicates adequate arterial blood flow.

Rationale 5: I am going to perform the Allens test to see if you have any varicose veins. The Allens test is used to determine if the client has problems with arterial blood flow from the radial and ulnar arteries to the clients hand.

Global Rationale: It is important for the nurse to assess the clients peripheral extremities to determine temperature. Hair growth on toes indicates adequate arterial blood flow. The Allens test is used to determine patency of the radial and ulnar arteries. The nurse should use a safety pin to assess the clients ability to feel dull and sharp sensations. The Trendelenburgs test can be used to determine if the client has varicose veins in the legs.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Describe techniques required for assessment of the peripheral vascular system.

Question 9

Type: MCSA

The nursing student is learning about blood pressure assessment and asks the instructor about blood pressure values. Which of the following responses is an accurate response?

1. A normal blood pressure always depends on the clients previous values.

2. A normal blood pressure is below 140/90.

3. A client with prehypertension has a blood pressure that is greater than 140/90.

4. A client with stage II hypertension has a blood pressure that is greater than 160/100.

Correct Answer: 4

Rationale 1: There are some specific guidelines set forth by the National Institutes of Health that can be used to classify a clients blood pressure as normal, prehypertension, stage I hypertension, and stage II hypertension.

Rationale 2: A normal blood pressure is actually less than 120 (systolic) and less than 80 (diastolic).

Rationale 3: A client with prehypertension will have a blood pressure of 120139 (systolic) and 8089 (diastolic).

Rationale 4: This is an accurate response. The client with stage II hypertension will have a blood pressure greater than or equal to 160 (systolic) and greater than or equal to 100 (diastolic).

Global Rationale: There are some specific guidelines set forth by the National Institutes of Health that can be used to classify a clients blood pressure as normal, prehypertension, stage I hypertension, and stage II hypertension. The client with stage II hypertension will have a blood pressure greater than or equal to 160 (systolic) and greater than or equal to 100 (diastolic). A normal blood pressure is actually less than 120 (systolic) and less than 80 (diastolic). A client with prehypertension will have a blood pressure of 120139 (systolic) and 8089 (diastolic).

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 10

Type: MCSA

The nurse is taking the blood pressure of a client. The nurse obtains the blood pressure in both of the clients arms. The nurse determines that there is a difference of 15 mm Hg in the systolic readings between the arms and repeats the assessment with the same results. The nurse suspects which of the following may have occurred in this situation?

1. Inaccurate technique

2. Anxiety

3. Unilateral arterial obstruction

4. Shock

Correct Answer: 3

Rationale 1: After repeating the procedure and determining the results were the same, the nurse would not necessarily assume that the technique was faulty.

Rationale 2: Client anxiety may result in a higher blood pressure reading. It would not result in a difference between blood pressures assessed in each arm.

Rationale 3: A difference of readings 10 mm Hg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding.

Rationale 4: If the client is developing clinical manifestations associated with shock, the nurse would most likely determine that the clients blood pressure is lower than normal. Shock would not result in a difference between blood pressures assessed in each arm.

Global Rationale: A difference of readings 10 mm Hg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding. After repeating the procedure and determining the results were the same, the nurse would not necessarily assume that the technique was faulty. Client anxiety may result in a higher blood pressure reading. It would not result in a difference between blood pressures assessed in each arm. If the client is developing clinical manifestations associated with shock, the nurse would most likely determine that the clients blood pressure is lower than normal. Shock would not result in a difference between blood pressures assessed in each arm.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 11

Type: MCSA

The nurse examines the peripheral vascular system of a client diagnosed with chronic bronchitis 22 years ago. The nurse examines the clients hand. Which of the following statements by the client is consistent with the clients diagnosis?

1. My fingers look so pointy and narrow at the ends.

2. My fingernails are as hard as a rock.

3. My nails always look a little bluish.

4. My nails have a lot of strange ridges in them.

Correct Answer: 3

Rationale 1: Many times, clients with a long-term history of chronic hypoxia such as chronic bronchitis, will exhibit clubbing of their fingers. The fingertips will look large at the ends.

Rationale 2: Clients with lung problems resulting in chronic hypoxia will more likely to complain that their nails are soft and spongy.

Rationale 3: This is a likely statement from someone who has a long history of disorder resulting in chronic hypoxia. The nails may look blue or gray due to oxygen deprivation.

Rationale 4: his is more likely the result of another disorder such as a nutritional deficiency.

Global Rationale: The statement regarding blueness is a likely statement from someone who has a long history of disorder resulting in chronic hypoxia. The nails may look blue or gray due to oxygen deprivation. Many times, clients with a long-term history of chronic hypoxia such as chronic bronchitis, will exhibit clubbing of their fingers. The fingertips will look large at the ends, not pointy and narrow. Clients with lung problems resulting in chronic hypoxia will more likely to complain that their nails are soft and spongy. Ridges in the nails are more likely the result of another disorder such as a nutritional deficiency.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 12

Type: MCSA

The nurse is documenting about an ulcer on the lateral aspect of the clients right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. To help determine information about the origin of the clients ulcer, which of the following pieces of the assessment will be most useful for the nurse?

1. Skin turgor

2. Calf measurements

3. Homans sign

4. Peripheral pulses

Correct Answer: 4

Rationale 1: The nurse can use information about the clients skin turgor to help assess the clients fluid balance.

Rationale 2: Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency.

Rationale 3: Homans sign can be used to help determine if the client has developed a deep vein thrombosis.

Rationale 4: Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time.

Global Rationale: Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time. The nurse can use information about the clients skin turgor to help assess the clients fluid balance. Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency. Homans sign can be used to help determine if the client has developed a deep vein thrombosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 13

Type: MCSA

The nurse is assessing a client admitted to the hospital for congestive heart failure and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the clients ankles. The clients history indicates that the client has had a myocardial infarction and a left mastectomy. The nurse would suspect which of the following causes for the edema in the left arm?

1. Impaired lymphatic drainage

2. Noncompliance with medication regimen

3. Right-sided heart failure

4. Excessive intake of sodium

Correct Answer: 1

Rationale 1: This client most likely has developed lymphedema due to the removal of lymph nodes during the clients mastectomy. This type of surgery can inhibit the bodys ability to drain lymph from the clients affected arm.

Rationale 2: Noncompliance with medication may result in edema that affects the clients bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way the lymph is able to drain from the clients extremity.

Rationale 3: Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph is not draining well from the clients arm.

Rationale 4: Increased sodium intake can result in edema. However, this would most likely result in bilateral peripheral edema.

Global Rationale: This client most likely has developed lymphedema due to the removal of lymph nodes during the clients mastectomy. This type of surgery can inhibit the bodys ability to drain lymph from the clients affected arm. Noncompliance with medication may result in edema that affects the clients bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way the lymph is able to drain from the clients extremity. Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph is not draining well from the clients arm. Increased sodium intake can result in edema. However, this would most likely result in bilateral peripheral edema.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 14

Type: MCSA

The nurse is completing an assessment on a client following a cardiac catheterization procedure. During the initial assessment, the nurse easily palpates the clients right dorsalis pedis and posterior tibial pulses. The pulses on the clients 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 of the following would be the most appropriate action for the nurse at this time?

1. Notify the healthcare provider immediately.

2. Assess for the clients right popliteal pulse.

3. Take the clients blood pressure.

4. Place the client in Trendelenburg position.

Correct Answer: 2

Rationale 1: The nurse should attempt to palpate the clients popliteal pulse. The healthcare provider should be notified, but the nurse should be prepared to provide information about the clients popliteal pulse during their conversation.

Rationale 2: This is the appropriate action at this time. This will help the nurse determine how much of this extremity is still receiving oxygenated blood.

Rationale 3: After the nurse assesses the clients popliteal pulses, it may be appropriate to check the clients vital signs prior to notifying the healthcare provider.

Rationale 4: Trendelenberg can be used to treat a client in shock. The information about the client does not indicate that the client has developed clinical manifestations associated with shock.

Global Rationale: The nurse should attempt to palpate the clients popliteal pulse. This will help the nurse determine how much of this extremity is still receiving oxygenated blood. After the nurse assesses the clients popliteal pulses, it may be appropriate to check the clients vital signs prior to notifying the healthcare provider. The healthcare provider should be notified, but the nurse should be prepared to provide information about the clients condition during their conversation. Trendelenberg can be used to treat a client in shock. The information about the client does not indicate that the client has developed clinical manifestations associated with shock.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 15

Type: MCMA

While assessing a client with a laceration on the clients left third finger, the nurse notes the presence of inflammation and swelling of the finger. The nurse might expect to find which of the following?

Standard Text: Select all that apply.

1. 1cm, nontender, soft, left brachial node

2. cm, tender, firm, left superior superficial inguinal node

3. 2 cm, tender, firm, left epitrochlear node

4. cm, nontender, firm, left ulnar node

5. cm, tender, firm, left axillary lymph node

Correct Answer: 3,5

Rationale 1: 1cm, nontender, soft, left brachial node. A 1 cm lymph node is not necessarily enlarged. Tenderness usually indicates the presence of infection. Firmness can indicate infection.

Rationale 2: 2 cm, tender, firm, left superior superficial inguinal node. An infected wound on the clients left third finger may result in a tender enlarged firm epitrochlear, brachial, and axillary lymph nodes. The left superior superficial inguinal node drains lymph from the clients left leg.

Rationale 3: 2 cm, tender, firm, left superior superficial inguinal node. Normally, the epitrochlear nodes are not palpable. A tender, firm and enlarged node such as this one may indicate the client has an infection. The epitrochlear node drains the forearm and third, fourth, and fifth fingers. A lymph node indicative of infection will be greater than 1 cm, tender, and mobile.

Rationale 4: 2 cm, nontender, firm, left ulnar node. The epitrochlear node drains lymph from the ulnar area. Lymph nodes in the arm are the following: subclavicular, central axillary, brachial, and epitrochlear.

Rationale 5: 2 cm, tender, firm, left axillary lymph node. The client with an infected wound on the left finger may have a tender enlarged lymph node in the axilla that can be found with light palpation.

Global Rationale: Normally, the epitrochlear nodes are not palpable. A tender, firm and enlarged node such as this one may indicate the client has an infection. The epitrochlear node drains the forearm and third, fourth, and fifth fingers. The client with an infected wound on the left finger may have a tender enlarged lymph node in the axilla that can be found with light palpation. A lymph node indicative of infection will be greater than 1 cm, tender, and mobile. The left superior superficial inguinal node drains lymph from the clients left leg. The epitrochlear node, not the ulnar node, drains lymph from the ulnar area. Lymph nodes in the arm are the following: subclavicular, central axillary, brachial, and epitrochlear.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 16

Type: MCMA

The nurse is performing the assessment of an elderly client recently diagnosed with arterial insufficiency due to atherosclerosis. Which of the following findings are consistent with this condition?

Standard Text: Select all that apply.

1. Bilateral pitting edema 3+ in ankles and feet

2. Carotid bruit present

3. Blood pressure 180/94

4. Peripheral pulses 1+/4+ in dorsalis pedis bilaterally

5. A pea-sized ulcer noted on the clients right great toe, no drainage, well-defined edges

Correct Answer: 2,3,4,5

Rationale 1: Bilateral pitting edema 3+ in ankles and feet. Bilateral pitting edema is most often attributed to right-sided heart failure.

Rationale 2: arotid bruit present. A narrowing of the carotid artery, as occurs with atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a bruit.

Rationale 3: Blood pressure 180/94. Clients with atherosclerosis and arterial insufficiency may have hypertension.

Rationale 4: Peripheral pulses 1+/4+ in dorsalis pedis bilaterally. Atherosclerosis and arterial insufficiency may result in decreased peripheral pulses.

Rationale 5: A pea-sized ulcer noted on the clients right great toe, no drainage, well-defined edges. The client with arterial insufficiency may develop ulcers such as this one.

Global Rationale: A narrowing of the carotid artery, as occurs with atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a bruit. Clients with atherosclerosis and arterial insufficiency may have hypertension. Atherosclerosis and arterial insufficiency may result in decreased peripheral pulses. The client with arterial insufficiency may develop ulcers such as this one. Bilateral pitting edema is most often attributed to right-sided heart failure.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system

Question 17

Type: MCSA

The nurse is caring for a client who may have an arterial obstruction in her right ulnar artery. Which of the following tests may be used to help determine the patency of this artery?

1. Trendelenburg test

2. Manual compression test

3. Homans sign

4. Allens test

Correct Answer: 4

Rationale 1: This test can be used to evaluate valve competence in the presence of varicosities.

Rationale 2: If varicose veins are present, the nurse can determine the length of the varicose vein and the competency of its valves with the manual compression test.

Rationale 3: The test to elicit a Homans sign can be used to help determine if the client has a thrombosis.

Rationale 4: The Allens test is used to evaluate the patency of both the radial and ulnar arteries.

Global Rationale: The Allens test is used to evaluate the patency of both the radial and ulnar arteries. The Trendelenberg test can be used to evaluate valve competence in the presence of varicosities. If varicose veins are present, the nurse can determine the length of the varicose vein and the competency of its valves with the manual compression test. The test to elicit a Homans sign can be used to help determine if the client has a thrombosis.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 18

Type: MCMA

The nurse is assessing a client who may have arterial insufficiency in the left lower leg. Which of the following are consistent with this diagnosis?

Standard Text: Select all that apply.

1. Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3

2. Skin is cool, tight, and shiny

3. When left leg is dependent, erythema is present

4. When left leg is elevated, pallor is present

5. Client complains of increased pain during rest periods

Correct Answer: 1,2,3,4

Rationale 1: Left dorsalis pedis pulse +1, right dorsalis pedis pulse +3. The client with arterial insufficiency may have diminished pulses. The pulse in the left foot is difficult to palpate, while the pulse in the right foot is strong and easy to palpate.

Rationale 2: Skin is cool, tight, and shiny. This finding is consistent with arterial insufficiency. The affected limb will feel cool. The skin may look tight and appear shiny. These findings indicate that the limb is not receiving an adequate arterial supply of oxygenated blood.

Rationale 3: When left leg is dependent, erythema is present. This finding is consistent with arterial insufficiency. When in a dependent position, the affected limbs will become reddened.

Rationale 4: When left leg is elevated, pallor is present. This finding is consistent with arterial insufficiency. When elevated, affected limbs will become pale.

Rationale 5: Client complains of increased pain during rest periods. The client with arterial insufficiency is more likely to complain of pain during exercise of the leg. The pain decreases or is absent with rest.

Global Rationale: The client with arterial insufficiency may have diminished pulses. The pulse in the left foot is difficult to palpate, but the pulse in the right foot is strong and easy to palpate. The affected limb will feel cool. The skin may look tight and appear shiny. These findings indicate that the limb is not receiving an adequate arterial supply of oxygenated blood. When in a dependent position, the affected limbs will become reddened. When elevated, affected limbs will become pale. The client with arterial insufficiency is more likely to complain of pain during exercise of the leg. The pain decreases or is absent with rest.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 19

Type: MCMA

The client was recently diagnosed with venous insufficiency. Which of the following statements by the client are consistent with this diagnosis?

Standard Text: Select all that apply.

1. My legs are so cold that they feel like ice.

2. My ankles and feet are always swollen.

3. The skin on my leg looks so pale.

4. When I walk around a lot, my legs just ache.

5. I have an ulcer on my inner leg above my ankle that just bleeds and bleeds.

Correct Answer: 2,5

Rationale 1: My legs are so cold that they feel like ice. Clients with arterial insufficiency may complain that their legs feel cool or cold. The nurse is more likely to determine that the legs of clients with venous insufficiency have temperatures that are within normal limits.

Rationale 2: My ankles and feet are always swollen. Edema in the lower extremities is associated with venous insufficiency.

Rationale 3: The skin on my leg looks so pale. Pale skin on the lower extremities is associated with arterial insufficiency. Venous insufficiency results in darkened skin on the lower extremities.

Rationale 4: When I walk around a lot, my legs just ache. This statement is consistent with a client who has been diagnosed with arterial insufficiency. The type of discomfort associated with venous insufficiency is aggravated by prolonged standing or sitting and is relieved by several hours of rest.

Rationale 5: I have an ulcer on my inner leg above my ankle that just bleeds and bleeds. This type of ulcer is consistent with a diagnosis of venous insufficiency. These ulcers are more likely to bleed and can be found in this area of the lower extremity. Arterial insufficiency ulcers are often described as dry, pale, with defined edges.

Global Rationale: Edema in the lower extremities is associated with venous insufficiency. The ulcers consistent with a diagnosis of venous insufficiency are likely to bleed and can be found in this area of the lower extremity. Arterial insufficiency ulcers are often described as dry, pale, with defined edges. Clients with arterial insufficiency may complain that their legs feel cool or cold. The nurse is more likely to determine that the legs of clients with venous insufficiency have temperatures that are within normal limits. Pale skin on the lower extremities is associated with arterial insufficiency. Venous insufficiency results in darkened skin on the lower extremities. Pain with walking is consistent with a client who has been diagnosed with arterial insufficiency. The type of discomfort associated with venous insufficiency is aggravated by prolonged standing or sitting and is relieved by several hours of rest.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 20

Type: MCSA

The client is visiting the healthcare providers office with complaints of discoloration of her hands. The client states, My fingertips turn whitish and then later they get really red. The nurse is not surprised to learn from the healthcare provider that the client has which of the following disorders?

1. Lymphedema

2. Raynauds disease

3. Thrombosis

4. Venous insufficiency

Correct Answer: 2

Rationale 1: Lymphedema is often described as edema that occurs in an affected extremity that is not draining lymph properly.

Rationale 2: The findings described are consistent with Raynauds disease, in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then redness. This condition is most commonly seen in young females.

Rationale 3: These findings are not consistent with a venous clot in the clients arm. Clients with clots may have no symptoms at all or may experience pain.

Rationale 4: Venous insufficiency results in discomfort that is aggravated by prolonged standing or sitting and is relieved by rest. The clients complaints are not consistent with venous insufficiency.

Global Rationale: The findings described are consistent with Raynauds disease, in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then redness. This condition is most commonly seen in young females. Lymphedema is often described as edema that occurs in an affected extremity that is not draining lymph properly. Clients with clots may have no symptoms at all or may experience pain. Venous insufficiency results in discomfort that is aggravated by prolonged standing or sitting and is relieved by rest. The clients complaints are not consistent with venous insufficiency.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 21

Type: MCSA

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 of the following responses by the nurses is most important at this time?

1. How much salt do you have in your diet?

2. Does the other arm swell also?

3. Tell me about your past surgical procedures.

4. Do you ever feel self-conscious about your arm?

Correct Answer: 3

Rationale 1: This client most likely has lymphedema. If salt intake was excessive, the nurse would also determine swelling in other extremities. Unilateral swelling indicates that there may be a problem with lymph drainage from the extremity.

Rationale 2: This is a good question but the nurse can see at this time that there is unilateral swelling. This is not the most important question to ask at this time.

Rationale 3: This is the most important thing for the nurse to determine. This information will help the nurse determine if the client has lymphedema due to a surgical procedure. Damage to or removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately.

Rationale 4: This is important for the nurse to determine. However, this is not the most important question to ask at this time. The nurse should seek to determine how the lymphedema developed.

Global Rationale: This client most likely has lymphedema. Damage to or removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately, so information about previous surgical procedures is the priority question. This information will help the nurse determine if the client has lymphedema due to a surgical procedure. If salt intake was excessive, the nurse would also find swelling in other extremities. Unilateral swelling indicates that there may be a problem with lymph drainage from the extremity. The clients feelings of being self-conscious are important for the nurse to consider, but are not the most important at this time. The nurse should seek to determine how the lymphedema developed.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 22

Type: MCSA

While performing the assessment of the clients peripheral vascular system, the nurse notes that there was a rapid filling of superficial veins during the Trendelenburg test. These findings would be most consistent with which of the following disorders?

1. Valve incompetence

2. Arterial insufficiency

3. Venous insufficiency

4. Phlebitis

Correct Answer: 1

Rationale 1: This is consistent with valve incompetence that is associated with the development of varicose veins in the lower extremities.

Rationale 2: The Trendelenberg test does not test for arterial insufficiency. The findings during the Trendelenberg test on this client demonstrate some issues with valve incompetence.

Rationale 3: The findings during this clients Trendelenberg test are consistent with valve incompetence, not venous insufficiency. The client with venous insufficiency will exhibit edema and a brownish discoloration in the lower extremities.

Rationale 4: Phlebitis is an inflammation of the vein. The Trendelenberg test is not used to determine if the client has phlebitis. The client with phlebitis will complain of tenderness along the affected area of the vein.

Global Rationale: This finding is consistent with valve incompetence that is associated with the development of varicose veins in the lower extremities. The Trendelenberg test does not test for arterial insufficiency. The findings are not consistent with venous insufficiency. The client with venous insufficiency will exhibit edema and a brownish discoloration in the lower extremities. Phlebitis is an inflammation of the vein. The Trendelenberg test is not used to determine if the client has phlebitis. The client with phlebitis will complain of tenderness along the affected area of the vein.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 23

Type: MCSA

A clients blood pressure is 138/86 mm Hg. The nurse classifies this clients blood pressure as which of the following categories?

1. Normal

2. Prehypertension

3. Stage I hypertension

4. Stage II hypertension

Correct Answer: 2

Rationale 1: Normal blood pressures are less than 120 (systolic) and less than 80 (diastolic).

Rationale 2: This blood pressure is classified as prehypertension because it is between 130 and 139 (systolic) and 80 and 89 (diastolic).

Rationale 3: Blood pressures falling into this category are those between 140 and 159 (systolic) or those between 90 and 99 (diastolic).

Rationale 4: Blood pressures falling into this category are those greater than or equal to 160 (systolic) or greater than 100 (diastolic).

Global Rationale: This blood pressure is classified as prehypertension because it is between 130 and 139 (systolic) and 80 and 89 (diastolic). Normal blood pressures are less than 120 (systolic) and less than 80 (diastolic). Blood pressures falling into the Stage I hypertension category are those between 140159 (systolic) or those between 90 and 99 (diastolic). Blood pressures falling into the stage II hypertension category are those greater than or equal to 160 (systolic) or greater than 100 (diastolic).

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.5: Differentiate normal from abnormal findings in physical assessment of the peripheral vascular system.

Question 24

Type: MCSA

The nurse is performing an assessment on a healthy 5 year old and palpates two enlarged lymph nodes on the childs neck. The lymph nodes are soft, mobile, nontender, and each is less than 1 cm in diameter. The nurse would choose which of the following actions in this situation?

1. Assess for an infected wound.

2. Document this as a normal finding.

3. Notify the healthcare provider.

4. Obtain an order for a throat culture.

Correct Answer: 2

Rationale 1: It is a normal finding to determine that a child has several enlarged lymph nodes such as these. When lymph nodes are significantly enlarged, the nurse should assess the child for an infection.

Rationale 2: This is appropriate since these enlarged lymph nodes are small, nontender, and mobile.

Rationale 3: t is not necessary for the nurse to notify the healthcare provider at this time.

Rationale 4: This would be an appropriate nursing action if the child had significantly enlarged lymph nodes and evidence that an infection was present in the childs pharynx.

Global Rationale: It is a normal finding to determine that a child has several enlarged lymph nodes such as these. When lymph nodes are significantly enlarged, the nurse should assess the child for an infection. Documenting this as a normal finding is appropriate since these enlarged lymph nodes are small, nontender, and mobile. It is not necessary for the nurse to notify the healthcare provider at this time. Obtaining an order for a throat culture would be an appropriate nursing action if the child had significantly enlarged lymph nodes and evidence that an infection was present in the childs pharynx.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the peripheral vascular system.

Question 25

Type: MCSA

The nurse is performing a peripheral vascular assessment of a female client who is 7 months pregnant. The nurse notes mild peripheral edema, all other findings were normal. Which of the following actions by the nurse would be appropriate?

1. Notify the healthcare provider immediately regarding this abnormal finding.

2. Obtain an order from the healthcare provider for a diuretic to reduce the clients edema.

3. Document the findings as expected due to the clients pregnancy.

4. Educate the client regarding ways to reduce the risk about peripheral vascular ulcer development.

Correct Answer: 3

Rationale 1: Mild peripheral edema is an expected finding when a pregnant client is in her third trimester. The clients healthcare provider does not need to be immediately notified.

Rationale 2: The client does not need a diuretic to reduce the mild peripheral edema. This is a normal finding at this stage of the clients pregnancy.

Rationale 3: Pressure from the uterus on the lower extremities can obstruct venous return and can cause edema, varicosities of the leg, and hemorrhoids. Edema is an expected finding because the client is in her third trimester.

Rationale 4: Peripheral edema is a normal finding at this stage of the clients pregnancy. This client is not necessarily at a greater risk for developing a peripheral vascular ulcer.

Global Rationale: Mild peripheral edema is an expected finding when a pregnant client is in her third trimester. Pressure from the uterus on the lower extremities can obstruct venous return and can cause edema, varicosities of the leg, and hemorrhoids. The clients healthcare provider does not need to be immediately notified. The client does not need a diuretic to reduce the mild peripheral edema. This client is not necessarily at a greater risk for developing a peripheral vascular ulcer.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the peripheral vascular system.

Question 26

Type: MCSA

A[1][2] 31-year-old female client wishes to begin taking oral contraceptives. The medical history indicates that the client had a deep vein thrombosis three years ago. After reviewing the objectives set forth in Healthy People 2020, which of the following is the best response by the nurse?

1. We can have the healthcare provider write you a prescription today.

2. You will also have to take blood thinners.

3. I need to perform a Homans test on you.

4. Taking oral contraceptives increases your risk of developing clots.

Correct Answer: 4

Rationale 1: This client has a history of deep vein thrombosis. Her history and taking oral contraceptive use increases her risk for developing another thrombosis.

Rationale 2: It would be better for this client to avoid using oral contraceptives and use another method of birth control. Blood thinners have significant side effects.

Rationale 3: At this time, the client has not been taking the oral contraceptives. There is no information to indicate the client currently has a deep vein thrombosis.

Rationale 4: This is an accurate response and the nurses best response.

Global Rationale: This client has a history of deep vein thrombosis. Her history and oral contraceptive use increases her risk for developing another thrombosis. It would be better for this client to avoid using oral contraceptives and use another method of birth control. Blood thinners have significant side effects. There is no information to indicate the client currently has a deep vein thrombosis so Homans test is not appropriate.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.7: Discuss the objectives in Healthy People 2020 as they relate to issues of the peripheral vascular system.

Question 27

Type: MCSA

The nurse is conducting a wellness presentation for a group of factory employees and notes a large number of African Americans present. Based on information included in Healthy People 2020, the nurse would choose which of the following topics as a priority for this setting?

1. Cancer risk reduction

2. Bone density assessments

3. Smoking cessation

4. Blood pressure screening

Correct Answer: 4

Rationale 1: African Americans do not typically have an increased risk of all types of cancers.

Rationale 2: African Americans do not have an increased risk of developing osteoporosis.

Rationale 3: Smoking cessation techniques are important to discuss, but hypertension is something that affects many African Americans.

Rationale 4: This is an appropriate activity because African Americans have an increased risk of developing hypertension.

Global Rationale: African Americans have an increased risk of developing hypertension. African Americans do not typically have an increased risk of all types of cancers or of developing osteoporosis. Smoking cessation techniques are important to discuss, but hypertension is something that affects many African Americans.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18.7: Discuss the objectives in Healthy People 2020 as they relate to issues of the peripheral vascular system.

Question 28

Type: MCMA

The nurse is caring for a male client who is complaining of dizziness when standing. The client has been compliant with his antihypertensive medication. Which of the following statements by the client are commonly associated with antihypertensive medication use?

Standard Text: Select all that apply.

1. Sometimes, I just feel so sick to my stomach.

2. I have frequent headaches.

3. My sex life hasnt been so good since I started taking this medication.

4. I have a rash all over my back.

5. I dont seem to pee as much as I did before I started this medication.

Correct Answer: 1,2,3

Rationale 1: Sometimes, I just feel so sick to my stomach. Nausea is associated with antihypertensive medication use.

Rationale 2: I have frequent headaches. Headaches can be associated with antihypertensive medication use.

Rationale 3: My sex life hasnt been so good since I started taking this medication. Clients who use antihypertensive medications to control their blood pressure might experience a decrease in their sex drive. Impotence can occur in male clients.

Rationale 4: I have a rash all over my back. This sign is not necessarily commonly associated with antihypertensive medication use.

Rationale 5: I dont seem to pee as much as I did before I started this medication. This is an atypical complaint. Clients who take diuretics to control their blood pressure may find that they are voiding more than usual.

Global Rationale: Nausea and headaches are associated with antihypertensive medication use. Clients who use antihypertensive medications to control their blood pressure might experience a decrease in their sex drive. Impotence can occur in male clients. Rashes are not necessarily commonly associated with antihypertensive medication use. Clients who take diuretics to control their blood pressure may find that they are voiding more than usual. This is not found with antihypertensive medications other than diuretics.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18.7: Discuss the objectives in Healthy People 2020 as they relate to issues of the peripheral vascular system.

Question 29

Type: MCMA

The client is a 38-year-old female client who developed a pulmonary embolism and is currently in the Intensive Care Unit. The nurse in the Intensive Care Unit is interviewing the client and reviewing her history. Which of the following statements by the client or assessment findings are consistent with the clients increased risk for developing a pulmonary embolism?

Standard Text: Select all that apply.

1. Client states, I usually smoke two packs of cigarettes each day.

2. Client states, The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldnt.

3. Client states, I had an open appendectomy 4 days ago. 4 cm incision noted to RLQ, staples intact, edges well-approximated

4. Client states, I have taken oral contraceptives for the last 7 years.

5. Client states, I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care.

Correct Answer: 1,2,3,4,5

Rationale 1: Client states, I usually smoke two packs of cigarettes each day. Cigarette smoke contains nicotine that produces vasoconstriction. Vasoconstriction of blood vessels increases the clients risk of developing a blood clot or a deep vein thrombosis.

Rationale 2: Client states, The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with him later that evening, but I was so nauseated and in so much pain that I couldnt. Ambulation following surgery is very important. Ambulation can reduce blood pooling in the calves and reduce the clients risk for clot formation. Immobility is a risk factor for blood clot formation.

Rationale 3: Client states, I had an open appendectomy 4 days ago. 4 cm incision noted to RLQ, staples intact, edges well-approximated . The clients history of a recent abdominal surgery increases the clients risk of developing a blood clot.

Rationale 4: Client states, I have taken oral contraceptives for the last 7 years. Oral contraceptive use is linked to increases risk of blood clot formation because of the way the medication works within the clients body.

Rationale 5: Client states, I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care. Muscle cramping and tenderness in the lower extremity are consistent with a deep vein thrombosis.

Global Rationale: Smoking cigarettes can increase the clients risk for developing a deep vein thrombosis that can turn into a pulmonary embolism. Ambulating after surgery is important to help prevent blood clots from forming. Major surgeries can increase the clients risk for developing a blood clot. Oral contraceptive use can increase the clients risk for clotting. The client most likely had a deep vein thrombosis before the pulmonary embolism developed.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.8: Apply critical thinking in selected simulations related to physical assessment of the peripheral vascular system.

Question 30

Type: HOTSPOT

The client developed a pulmonary embolism. Draw an arrow pointing toward the most distal area of the lower extremity from where the embolism most likely originated.

Screen Shot 2015-09-24 at 12.27.45 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The client is more likely to have developed a blood clot within the calf. Blood clots can develop in the popliteal area as well but this site is less distal than the calf.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.8: Apply critical thinking in selected simulations related to physical assessment of the peripheral vascular system.

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