NSG 3160 Exam 3 | NSG 3160 Health Assessment |
Actual Q&A with Rationale (NSG 3160 Exam 3) |
Galen
Peripheral Vascular System
1. A nurse is assessing a patient's peripheral vascular system. Which of the following
is the most important risk factor for peripheral arterial disease (PAD)?
a) Hypertension
b) Diabetes mellitus
c) Smoking
d) Hyperlipidemia
Correct Answer: c) Smoking
Rationale: Smoking is the single most important modifiable risk factor for peripheral
arterial disease. It causes vasoconstriction, endothelial damage, and accelerates
atherosclerosis. While diabetes, hypertension, and hyperlipidemia are also risk factors,
smoking has the strongest association.
2. Which of the following findings is most consistent with chronic venous
insufficiency?
a) Thin, shiny skin with hair loss
b) Brownish discoloration of the lower legs
c) Weak or absent pedal pulses
d) Intermittent claudication
Correct Answer: b) Brownish discoloration of the lower legs
Rationale: Chronic venous insufficiency leads to venous stasis, causing hemosiderin
deposition in the tissues, which results in a brownish discoloration (stasis dermatitis) of
the lower legs. Thin, shiny skin with hair loss and weak pulses are characteristic of
arterial insufficiency. Intermittent claudication is also arterial.
3. A nurse is assessing a patient with peripheral arterial disease. Which of the
following symptoms would the patient most likely report?
a) Leg pain that worsens with elevation
b) Leg pain that improves with walking
c) Leg pain that is relieved by standing
d) Leg pain that is worse at the end of the day
Correct Answer: a) Leg pain that worsens with elevation
, Rationale: In PAD, arterial blood flow is insufficient. Elevation of the leg further reduces
blood flow, worsening pain. Dependency (hanging the leg down) improves blood flow
and relieves pain. Venous insufficiency pain improves with elevation and worsens with
dependency.
4. Which of the following is a characteristic of an arterial ulcer?
a) Located on the medial malleolus
b) Wound edges are irregular and shallow
c) Wound base is pale and dry
d) Surrounding skin is edematous and brown
Correct Answer: c) Wound base is pale and dry
Rationale: Arterial ulcers are caused by ischemia; the wound base is pale, dry, and
often necrotic. They are typically located on the toes, heels, or lateral malleolus. Venous
ulcers are located on the medial malleolus, have irregular edges, and are surrounded by
brown, edematous skin.
5. A nurse is assessing a patient's pedal pulses. Which pulse is most commonly
palpated on the dorsum of the foot?
a) Posterior tibial pulse
b) Dorsalis pedis pulse
c) Popliteal pulse
d) Femoral pulse
Correct Answer: b) Dorsalis pedis pulse
Rationale: The dorsalis pedis pulse is located on the dorsum of the foot, between the
first and second metatarsals. The posterior tibial pulse is located behind the medial
malleolus. The popliteal pulse is behind the knee, and the femoral pulse is in the groin.
6. Which of the following is a normal finding when assessing the capillary refill time?
a) Less than 2 seconds
b) 2 to 3 seconds
c) 3 to 5 seconds
d) Greater than 5 seconds
Correct Answer: a) Less than 2 seconds
Rationale: Normal capillary refill time is less than 2 seconds. A prolonged refill time (>3
seconds) indicates decreased peripheral perfusion, which may be seen in shock,
dehydration, or peripheral arterial disease.
Actual Q&A with Rationale (NSG 3160 Exam 3) |
Galen
Peripheral Vascular System
1. A nurse is assessing a patient's peripheral vascular system. Which of the following
is the most important risk factor for peripheral arterial disease (PAD)?
a) Hypertension
b) Diabetes mellitus
c) Smoking
d) Hyperlipidemia
Correct Answer: c) Smoking
Rationale: Smoking is the single most important modifiable risk factor for peripheral
arterial disease. It causes vasoconstriction, endothelial damage, and accelerates
atherosclerosis. While diabetes, hypertension, and hyperlipidemia are also risk factors,
smoking has the strongest association.
2. Which of the following findings is most consistent with chronic venous
insufficiency?
a) Thin, shiny skin with hair loss
b) Brownish discoloration of the lower legs
c) Weak or absent pedal pulses
d) Intermittent claudication
Correct Answer: b) Brownish discoloration of the lower legs
Rationale: Chronic venous insufficiency leads to venous stasis, causing hemosiderin
deposition in the tissues, which results in a brownish discoloration (stasis dermatitis) of
the lower legs. Thin, shiny skin with hair loss and weak pulses are characteristic of
arterial insufficiency. Intermittent claudication is also arterial.
3. A nurse is assessing a patient with peripheral arterial disease. Which of the
following symptoms would the patient most likely report?
a) Leg pain that worsens with elevation
b) Leg pain that improves with walking
c) Leg pain that is relieved by standing
d) Leg pain that is worse at the end of the day
Correct Answer: a) Leg pain that worsens with elevation
, Rationale: In PAD, arterial blood flow is insufficient. Elevation of the leg further reduces
blood flow, worsening pain. Dependency (hanging the leg down) improves blood flow
and relieves pain. Venous insufficiency pain improves with elevation and worsens with
dependency.
4. Which of the following is a characteristic of an arterial ulcer?
a) Located on the medial malleolus
b) Wound edges are irregular and shallow
c) Wound base is pale and dry
d) Surrounding skin is edematous and brown
Correct Answer: c) Wound base is pale and dry
Rationale: Arterial ulcers are caused by ischemia; the wound base is pale, dry, and
often necrotic. They are typically located on the toes, heels, or lateral malleolus. Venous
ulcers are located on the medial malleolus, have irregular edges, and are surrounded by
brown, edematous skin.
5. A nurse is assessing a patient's pedal pulses. Which pulse is most commonly
palpated on the dorsum of the foot?
a) Posterior tibial pulse
b) Dorsalis pedis pulse
c) Popliteal pulse
d) Femoral pulse
Correct Answer: b) Dorsalis pedis pulse
Rationale: The dorsalis pedis pulse is located on the dorsum of the foot, between the
first and second metatarsals. The posterior tibial pulse is located behind the medial
malleolus. The popliteal pulse is behind the knee, and the femoral pulse is in the groin.
6. Which of the following is a normal finding when assessing the capillary refill time?
a) Less than 2 seconds
b) 2 to 3 seconds
c) 3 to 5 seconds
d) Greater than 5 seconds
Correct Answer: a) Less than 2 seconds
Rationale: Normal capillary refill time is less than 2 seconds. A prolonged refill time (>3
seconds) indicates decreased peripheral perfusion, which may be seen in shock,
dehydration, or peripheral arterial disease.
