Download Chapter 20: Peripheral Vascular System and Lymphatic SystemJarvis: and more Exams Nursing in PDF only on Docsity!
Chapter 20: Peripheral Vascular System and Lymphatic SystemJarvis:
Physical Examination & Health Assessment, 7th Edition
MULTIPLE CHOICE
- Which statement 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 the veins. d. (^) Arteries can greatly expand to accommodate a large blood volume increase. ANS: B The pumping heart makes the arterial system a high-pressure system.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 509 MSC: Client Needs: General
- 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 ANS: C 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.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 509 MSC: Client Needs: General
- The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location forpalpation? 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
ANS: D 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. No pulse is palpated at the lateral malleolus.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 509
d. Superficial
ANS: D The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 510 MSC: Client Needs: General
- A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the greatsaphenous vein for the coronary bypass grafts. The patient asks, “What happens to my circulation when this vein is removed?” The nurse should reply: a. (^) “Venous insufficiency is a common problem after this type of surgery.” b. (^) “Oh, you have lots of veins—you won’t even notice that it has been removed.” c. (^) “You will probably experience decreased circulation after the vein is removed.” d. (^) “This vein can be removed without harming your circulation because the deeperveins in your leg are in good condition.” ANS: D As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming circulation. The other responses are not correct.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 510 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- The nurse is reviewing the risk factors for venous disease. Which of these situations bestdescribes a person at highest risk for the 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 habit d. (^) Older adult taking anticoagulant medication ANS: B People who undergo prolonged standing, sitting, or bed rest are at risk for venous disease. Hypercoagulable (not anticoagulated) states and vein-wall trauma also place the person at risk for venous disease. Obesity and the late months of pregnancy are also risk factors.
DIF: Cognitive Level: Applying (Application) REF: p. 512 MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
- The nurse is teaching a review class on the lymphatic system. A participant shows correctunderstanding 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; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.” ANS: B
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- When performing an assessment of a patient, the nurse notices the presence of an enlargedright 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 health history questions regarding any recent ear infections or sorethroats. d. (^) Examine the patient’s lower arm and hand, and check for the presence of infection or lesions. ANS: D 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.
DIF: Cognitive Level: Applying (Application) REF: p. 513 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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. (^) Pelletlike nodes in the supraclavicular region ANS: B 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.
DIF: Cognitive Level: Applying (Application) REF: p. 513 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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. (^) Presence of palpable lymph nodes c. (^) No palpable nodes 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
ANS: B
Lymph nodes are relatively large in children, and the superficial ones are often palpable even when the child is healthy.
DIF: Cognitive Level: Applying (Application) REF: p. 514 MSC: Client Needs: Health Promotion and Maintenance
b. (^) Problems related to arterial insufficiency. c. (^) Problems related to venous insufficiency. d. (^) Pain related to musculoskeletal abnormalities.
ANS: B Night leg pain is common in aging adults and 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.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 515 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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. ANS: B The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 516 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- The nurse is performing an assessment on an adult. The adult’s vital signs are normal, andcapillary refill time is 5 seconds. What should the nurse do next? a. (^) Ask the patient about a history of frostbite. b. (^) Suspect that the patient has venous insufficiency. c. (^) Consider this a delayed capillary refill time, and investigate further. d. (^) Consider this a normal capillary refill time that requires no further assessment. ANS: C 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.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 516 MSC: Client Needs: Health Promotion and Maintenance
- 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. ANS: B
- 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. Next, the nurseshould: a. (^) Check for the presence of claudication. b. (^) Refer the individual for further evaluation. c. (^) Consider this finding as normal, and proceed with the peripheral vascularevaluation. d. (^) Ask the patient if he or she has experienced any unusual cramping or tingling in the arm. ANS: C Palpating the ulnar pulses is not usually necessary. The ulnar pulses are not often palpable in the normal person. The other responses are not correct.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 517 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- The nurse is assessing the pulses of a patient who has been admitted for untreatedhyperthyroidism. The nurse should expect to find a(n) pulse. a. (^) Normal b. (^) Absent c. (^) Bounding d. (^) Weak, thready ANS: C A full, bounding pulse occurs with hyperkinetic states (e.g., exercise, anxiety, fever), anemia, and hyperthyroidism. An absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 517 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- The nurse is preparing to perform a modified Allen test. Which is an appropriate reason forthis 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 radialartery d. (^) To evaluate the venous refill rate that occurs after the ulnar and radial arteries are
temporarily occluded
ANS: C
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 518 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 521 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
a. 1+/0-4+ b. (^) 3+/0-4+ c. (^) 4+/0-4+ d. (^) Brawny edema ANS: A 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.
DIF: Cognitive Level: Applying (Application) REF: p. 523 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has noedema. Based on these findings, the nurse recalls that: a. (^) Nonpitting, hard edema occurs with lymphatic obstruction. b. (^) Alterations in arterial function will cause edema. c. (^) Phlebitis of a superficial vein will cause bilateral edema. d. (^) Long-standing arterial obstruction will cause pitting edema. ANS: A 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).
DIF: Cognitive Level: Applying (Application) REF: p. 523 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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 isexperiencing pulsus: a. (^) Alternans. b. (^) Bisferiens. c. (^) Bigeminus. d. (^) Paradoxus. ANS: D
a. Significant elevational pallor. b. (^) Venous filling within 15 seconds. c. (^) No change in the coloration of the skin. d. (^) Color returning to the feet within 20 seconds of assuming a sitting position. ANS: B 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. Significant elevational pallor, as well as delayed venous filling, occurs with arterial insufficiency.
DIF: Cognitive Level: Applying (Application) REF: p. 524 MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- During a visit to the clinic, 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 thatthe patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflectedby these findings? a. (^) Deep-vein thrombophlebitis b. (^) Varicose veins c. (^) Lymphedema d. (^) Raynaud phenomenon ANS: B Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins 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 observed on assessment. (See Table 20-5 for the description of deep-vein thrombophlebitis. See Table 20- for descriptions of Raynaud phenomenon and lymphedema.)
DIF: Cognitive Level: Applying (Application) REF: p. 526 MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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 aleft-sided mastectomy 1 year ago. The nurse suspects which problem? a. (^) Venous stasis b. (^) Lymphedema c. (^) Arteriosclerosis d. (^) Deep-vein thrombosis
ANS: B
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 lymphedema can impede drainage of lymph. The other responses are not correct.
