Chapter 20

Front 1

A patient who is in the third trimester of pregnancy has generalized edema and a blood pressure of 140/90 mm Hg. Which complication should the nurse look for in the patient?

Back 1

Preeclampsia

Front 2

While assessing a patient with chronic venous insufficiency, the nurse finds dilated, bulged, and tortuous veins. The patient also reports severe leg cramps. Which technique helps in further assessing the patient’s medical condition?

Back 2

Doppler ultrasound

Front 3

After measuring the distal calf of a patient, the nurse documents that the patient has moderate lymphedema. Which findings support this conclusion?

Back 3

Asymmetry of calves measuring 4.0 cm

Front 4

A patient’s laboratory reports show the highest left average ankle pressure at 130 mm Hg and the highest left average arm pressure is 129 mm Hg. What is the left ankle-brachial index (ABI) in the patient? Record your answer using a whole number. ________

Back 4

Left ABI can be determined using the formula left ABI = highest left average ankle pressure (dorsalis pedis [DP] or posterior tibial [PT])/highest average arm pressure (right or left). In this case, the highest average ankle pressure of the patient is 130 mm Hg, and the highest average left arm pressure is 129 mm Hg. Therefore, the left ABI = 130/129 = 1.007, or 1.

Front 5

While assessing a patient with an infection on the hand, the nurse uses one hand to shake the patient’s hand and keeps the other hand near the patient’s elbow. What could be the reason for the nurse’s action?

Back 5

To check for enlarged epitrochlear nodes

Front 6

A nursing instructor is preparing a lecture about inguinal nodes of the lymphatic system. Which statements should the instructor include in the lecture? Select all that apply.

Back 6

he inguinal nodes drain the lymph of the lower extremities.

The inguinal nodes drain the lymph of the external genitalia.

The inguinal nodes drain the lymph of the anterior abdominal wall.

Front 7

While assessing a patient with congenital cyanotic heart disease, the nurse finds that the patient has a flattened nail bed angle and diffuse enlargement of the terminal phalanges. Which technique does the nurse use for the assessment?

Back 7

Profile sign

Front 8

The nurse is caring for a patient with atherosclerosis. Which intervention should the nurse follow to obtain this patient’s ankle-brachial index?

Back 8

Maintain the room temperature at 22o C (72o F).

Front 9

A patient with atherosclerosis complains of foot pain while walking and at rest. The nurse finds that the patient has pale skin and rigid nails. Which complication does the nurse expect in the patient?

Back 9

Arterial ischemic ulcer

Front 10

The nurse is determining the ankle-brachial index (ABI) in a patient and finds it to be 0.85. What does the nurse deduce from this finding?

Back 10

The patient has mild peripheral artery disease.

Front 11

While the nurse is performing a peripheral vascular examination, the patient says, "I wake up in the middle of the night because of sudden pain in my legs." What does the nurse infer from the patient’s statement?

Back 11

The patient may have restless leg syndrome.

Front 12

What is a characteristic of the great saphenous vein?

Back 12

The great saphenous vein is located inside the leg.

Front 13

During the peripheral vascular examination of a patient, the nurse palpates the radial artery and documents the amplitude of the radial pulse as full, increased, and bounding. What does the nurse expect to find in the patient’s laboratory report? Select all that apply.

Back 13

Decreased red blood cell count

Increased serum thyroxine levels

Front 14

The nurse is caring for a patient who has brawny edema and unilateral swelling. The nurse finds that the patient has heavy arms and gets tired easily. Which nursing intervention will help to alleviate these signs and symptoms? Select all that apply.

Back 14

Suggesting the patient use nonelastic garments

Suggesting the patient use compression garments

Advising the patient to perform decongestive physiotherapy

Front 15

After observing a patient’s leg discoloration, the student nurse documents that the patient may have arterial insufficiency. The nurse checks the medical history of the patient and informs the student nurse that the assessment results are unreliable. What could be the reason for the unreliability of the assessment results?

Back 15

The patient has venous disease.

Front 16

The nurse is caring for an elderly patient who says, "I’ve been having severe leg pain." If the patient’s ankle-brachial index (ABI) is 0.65, what conditions should the nurse check for in the medical records? Select all that apply.

Back 16

Arthritis

Peripheral neuropathy

Front 17

While assessing the radial pulse of the patient, the nurse finds that the strength of the pulse increases rapidly and collapses subsequently. Which conditions may be responsible for this finding in the patient? Select all that apply.

Back 17

Patent ductus arteriosus

Aortic valve regurgitation

Front 18

The nurse is assessing a patient with cyanosis who has numbness and bluish discoloration of the skin. Which other signs and symptoms in the patient would support the diagnosis of Raynaud’s phenomenon? Select all that apply.

Back 18

Swelling in the arms

Burning pain in the arms

Front 19

The nurse finds that a patient has risk of atherosclerosis. What advice would the nurse provide to the patient to prevent further complications? Select all that apply.

Back 19

Avoid smoking cigarettes.

Avoid a sedentary lifestyle.

Reduce the intake of fatty foods.

Front 20

The nurse documents the pulse of the patient as weak and thready (1+). Which conditions in the patient does the nurse identify as the reason for such findings? Select all that apply.

Back 20

Shock

Peripheral artery disease (PAD)

Front 21

Which actions may aggravate the symptoms of venous insufficiency? Select all that apply.

Back 21

Sitting

Prolonged standing

Front 22

Which site is most suitable for palpation of the popliteal pulse?

Back 22

Below the knee

Front 23

A patient with severe leg pain has edema and weeping ulcers on the ankles. The patient tells the nurse, "My leg pain gets worse by the end of the day, but it feels a bit better when I walk or lay on the bed." What does the nurse interpret from these signs and symptoms?

Back 23

The patient has chronic venous pain.

Front 24

The nurse is assessing a patient who uses oral contraceptives and is at risk for deep vein thrombosis. Which medication would be helpful to ensure the patient’s safety?

Back 24

Clopidogrel (Plavix)

Front 25

The student nurse is discussing the physiologic changes that occur in the body because of cigarette smoking. What statement by the student nurse needs correction by the instructor?

Back 25

"Smoking decreases coagulability."

Front 26

The primary health care provider instructs the nurse to determine the ankle-brachial index (ABI) in a patient to know the severity of peripheral artery disease (PAD). Which conditions should the nurse check for in the patient’s medical record before determining the ABI? Select all that apply.

Back 26

Renal failure

Diabetes mellitus

Front 27

The nurse is assessing the probability of deep venous thrombosis (DVT) in a patient. What should the nurse do to assess the probability of DVT in the patient?

Back 27

Measure the calf circumference of both legs at the same place

Front 28

For which complications should the nurse monitor in a patient with deep vein thrombosis? Select all that apply.

Back 28

Heart Failure

Myocardial infarction

Front 29

The nurse is caring for a patient who has lymphatic obstruction. Which complication does the nurse monitor for in the patient? Select all that apply.

Back 29

Heart failure

Hepatic cirrhosis

Nephrosis

Front 30

The nurse records the patient’s blood pressure at 85/60 mm Hg for inspiration and 110/60 mm Hg for expiration. Which conditions are likely to be associated with this finding? Select all that apply.

Back 30

Acute asthma

Cardiac tamponade

Front 31

A patient who has undergone radiation therapy for breast cancer has brawny edema and unilateral swelling. The patient tells the nurse, "I feel tired all the time. My arms become so heavy, and my jewelry does not fit anymore." Which condition is the patient likely to have?

Back 31

Early lymphedema

Front 32

While assessing a patient with venous insufficiency, the nurse finds that the patient has edema in the lower extremities. The nurse also finds that the skin of the lower extremities is thick and has brownish discoloration. What could be the reason for such findings in the patient?

Back 32

Degradation of red blood cells

Front 33

The nurse is finding it difficult to locate an elderly patient’s pulse. After palpating the patient’s arm for some time, the nurse locates the pulse but notices it is obliterated on applying pressure. What do these findings indicate? Select all that apply.

Back 33

The patient may have aortic valve stenosis.

The patient may have decreased cardiac output.

The patient may have peripheral arterial disease.

Front 34

After reviewing the laboratory reports of a patient, the nurse concludes that the patient is at risk of atherosclerosis. Which findings support this conclusion? Select all that apply.

Back 34

Increase in the serum glucose levels

Increase in the serum cholesterol levels

Increase in the serum triglyceride levels

Front 35

An adolescent patient with an upper respiratory tract infection complains of abdominal pain. What could be the reason for this symptom?

Back 35

Inflammation of the mesenteric lymph nodes

Front 36

The laboratory reports of a patient show that the highest right average ankle pressure is 120 mm Hg and the highest average right arm pressure is 129 mm Hg. What do these findings indicate?

Back 36

The patient is at borderline cardiovascular risk.

Front 37

Arrange the order of the steps that the nurse should follow to determine the weak peripheral pulse of a patient by using a Doppler ultrasonic probe.

Back 37

Place the patient in a supine position with the legs rotated externally.

Place a drop of coupling gel at the end of the handheld transducer.

Place the transducer over the pulse site at a 90° angle.

Apply very light pressure and locate the pulse site.

Front 38

A bedridden patient with hypertension reports sudden sharp pain in the legs. The nurse finds the patient’s legs to be warm, red, and edematous. Which class of medications would be most beneficial for the patient?

Back 38

Anticoagulants

Front 39

The nurse observes bilateral pitting edema and abnormal distention of the jugular veins in a patient. Which condition is the patient likely to have?

Back 39

Pulmonary hypertension

Front 40

The nurse is preparing a patient to determine ankle-brachial index (ABI). The nurse finds that the patient has smoked 5 minutes before coming for the test. What is the most important nursing intervention in this situation?

Back 40

Conducting the test 2 hours later

Front 41

After measuring pitting edema in a patient, the nurse documents it as +4 grade. Which findings support the nurse’s documentation? Select all that apply.

Back 41

The patient has very deep pitting.

The patient has grossly swollen legs.

The patient has indentation of long duration.

Front 42

Arrange the order of steps that the nurse should follow to check a patient’s popliteal pulse.

Back 42

Relax the leg against the arm and press deeply with two thumbs.

Extend the leg and curl the fingers around the popliteal fossa.

Press the fingers hard on the artery against the bone.

Place the patient in the prone position and then lift the lower leg.

Front 43

A patient who is in the third trimester of pregnancy has increased venous pressure and reduced blood flow because of obstruction of the iliac veins and inferior vena cava. Which complications may the patient develop related to these findings? Select all that apply.

Back 43

Hemorrhoids

Varicosities in the vulva

Varicosities in the legs

Front 44

The nurse is assessing the probability of deep vein thrombosis (DVT) in a patient. While performing the pretest, the nurse documents the clinical characteristics as swelling of the entire leg, collateral superficial non-varicose veins, localized tenderness along the distribution of the deep venous system, and an alternative diagnosis likely to be DVT. What is the total score of DVT probability in this patient? Record your answer using a whole number. ________

Back 44

The clinical characteristics documented during the pretest are swelling of the entire leg = 1; collateral superficial non-varicose veins = 1; localized tenderness along the deep venous distribution = 1; alternate diagnosis likely to be DVT = –2. Therefore, the total score of DVT probability in the patient will be 1 + 1 + 1 – 2 = 1.

Front 45

The nurse is teaching a nursing student about the functions of the spleen. Which statement by the student nurse is a misunderstanding that needs correction?

Back 45

"The spleen stores old red blood cells."

Front 46

The nurse is assessing an elderly patient for the presence of peripheral vascular complications. Which nursing actions are appropriate during a peripheral vascular examination? Select all that apply.

Back 46

Checking the epitrochlear nodes of the patient

Palpating the femoral pulse of the patient

Palpating the inguinal nodes of the patien

Front 47

The nurse is preparing a patient for a modified Allen test. What action should the nurse take while performing the test?

Back 47

Tell the patient to blanch the hand by making a fist several times

Front 48

While assessing a patient with acute asthma, the nurse concludes that the patient may have pulsus paradoxus. Which finding supports the nurse’s conclusion?

Back 48

The patient’s blood pressure falls to 100/70 mm Hg during inspiration.

Front 49

The nurse observes that a patient’s pulse is easily palpable and pounds under the fingertips. What can the nurse infer from these findings? Select all that apply

Back 49

The patient is anemic.

The patient is in a hyperkinetic state.

The patient may have hyperthyroidism

Front 50

While performing peripheral vascular examination in a patient by using capillary refill, the nurse finds that the refill lasts for 5 seconds. What does the nurse interpret from this finding?

Back 50

The patient is at risk of hypovolemia.

Front 51

What advice should the nurse provide to a diabetic patient to prevent foot problems? Select all that apply.

Back 51

Avoid leaving chipped nail polish on.

Avoid covering discolored nails with nail polish.

Front 52

The nurse is teaching a patient with diabetes about foot care. Which instructions should the nurse include about maintaining blood flow to the feet? Select all that apply.

Back 52

Curl and spread out the toes frequently.

Take a warm footbath occasionally.

Front 53

The nurse is caring for an obese patient with atherosclerosis. According to the laboratory reports, the patient has high serum cholesterol levels. Which other complication does the nurse expect in the patient?

Back 53

Aortic aneurysm