2025 Health Assessment Exam 3: Ultimate Review
Guide with Practice Questions, Answers, and
Rationales for Nursing Students"
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 is experiencing pulsus:
A)
alternans.
B)
bisferiens.
C)
bigeminus.
D)
paradoxus. - - correct ans- -ANS: D
In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger
amplitude with expiration. It is best determined during blood pressure measurement;
reading decreases (>10 mm Hg) during inspiration and increases with expiration.
The nurse is performing a peripheral vascular assessment on a bedridden patient and
notices the following findings in the right leg: increased warmth, swelling, redness,
tenderness to palpation, and a positive Homan's sign. The nurse should:
A)
reevaluate the patient in a few hours.
B)
consider this a normal finding for a bedridden patient.
C)
seek emergency referral because of the risk of pulmonary embolism.
,D)
ask the patient to raise his leg off of the bed and check for pain on elevation. - - correct
ans- -ANS: C
Increased warmth, swelling, redness, and tenderness in the lower extremities require
emergency referral because of the risk of pulmonary embolism from a deep vein
thrombosis.
During an assessment the nurse has elevated a patient's legs 12 inches off the table
and has had him wag his feet to drain off venous blood. After helping him to sit up and
dangle his legs over the side of the table, the nurse should expect a normal finding at
this point would be:
A)
marked elevational pallor.
B)
venous filling within 15 seconds.
C)
no change in coloration of the skin.
D)
color returning to the feet within 20 seconds of assuming a sitting position - - correct
ans- -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. Marked elevational pallor as well as delayed
venous filling occurs with arterial insufficiency.
During a clinic visit, 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 that the patient has dilated, tortuous veins in her lower legs. Which condition is
reflected by these findings?
A)
Deep vein thrombophlebitis
B)
Varicose veins
,C)
Lymphedema
D)
Raynaud's phenomenon - - correct ans- -ANS: B
Superficial varicose veins are caused by incompetent distant valves on veins, which
results in reflux of blood and producing dilated, tortuous veins. They 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 seen
on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See
Table 20-2 for descriptions of Raynaud's phenomenon and lymphedema.
The nurse is preparing to perform a manual compression test on a patient. Which of
these statements is true about this procedure?
A)
Rapid filling of the veins indicates incompetent veins.
B)
Competent valves in the veins will transmit a wave to the distal fingers.
C)
A palpable wave transmission occurs when the valves are incompetent.
D)
The test assesses whether the valves of varicosity are competent when the person is in
the supine position. - - correct ans- -ANS: C
With the manual compression test, a palpable wave transmission occurs when the
valves are incompetent. Competent veins will prevent a wave transmission and the
nurse's distal (lower) fingers will feel no change. The test is performed while the patient
is standing.
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 a left-sided mastectomy 1 year ago. The nurse suspects which
problem?
A)
, Venous stasis
B)
Lymphedema
C)
Arteriosclerosis
D)
Deep vein thrombosis - - correct ans- -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 it can impede drainage of lymph. The other responses are not correct.
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which
statement about the ABI is true?
A)
Normal ABI indices are from 0.50 to 1.0.
B)
The normal ankle pressure is slightly lower than the brachial pressure.
C)
The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals.
D)
An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild
claudication. - - correct ans- -ANS: D
Use of the Doppler stethoscope is a noninvasive way to determine the extent of
peripheral vascular disease. The normal ankle pressure is slightly greater than or equal
to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral
vascular disease and mild claudication. The ABI is less reliable in patients with diabetes
mellitus because of claudication, which makes the arteries noncompressible and may
give a falsely high ankle pressure.
Guide with Practice Questions, Answers, and
Rationales for Nursing Students"
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 is experiencing pulsus:
A)
alternans.
B)
bisferiens.
C)
bigeminus.
D)
paradoxus. - - correct ans- -ANS: D
In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger
amplitude with expiration. It is best determined during blood pressure measurement;
reading decreases (>10 mm Hg) during inspiration and increases with expiration.
The nurse is performing a peripheral vascular assessment on a bedridden patient and
notices the following findings in the right leg: increased warmth, swelling, redness,
tenderness to palpation, and a positive Homan's sign. The nurse should:
A)
reevaluate the patient in a few hours.
B)
consider this a normal finding for a bedridden patient.
C)
seek emergency referral because of the risk of pulmonary embolism.
,D)
ask the patient to raise his leg off of the bed and check for pain on elevation. - - correct
ans- -ANS: C
Increased warmth, swelling, redness, and tenderness in the lower extremities require
emergency referral because of the risk of pulmonary embolism from a deep vein
thrombosis.
During an assessment the nurse has elevated a patient's legs 12 inches off the table
and has had him wag his feet to drain off venous blood. After helping him to sit up and
dangle his legs over the side of the table, the nurse should expect a normal finding at
this point would be:
A)
marked elevational pallor.
B)
venous filling within 15 seconds.
C)
no change in coloration of the skin.
D)
color returning to the feet within 20 seconds of assuming a sitting position - - correct
ans- -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. Marked elevational pallor as well as delayed
venous filling occurs with arterial insufficiency.
During a clinic visit, 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 that the patient has dilated, tortuous veins in her lower legs. Which condition is
reflected by these findings?
A)
Deep vein thrombophlebitis
B)
Varicose veins
,C)
Lymphedema
D)
Raynaud's phenomenon - - correct ans- -ANS: B
Superficial varicose veins are caused by incompetent distant valves on veins, which
results in reflux of blood and producing dilated, tortuous veins. They 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 seen
on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See
Table 20-2 for descriptions of Raynaud's phenomenon and lymphedema.
The nurse is preparing to perform a manual compression test on a patient. Which of
these statements is true about this procedure?
A)
Rapid filling of the veins indicates incompetent veins.
B)
Competent valves in the veins will transmit a wave to the distal fingers.
C)
A palpable wave transmission occurs when the valves are incompetent.
D)
The test assesses whether the valves of varicosity are competent when the person is in
the supine position. - - correct ans- -ANS: C
With the manual compression test, a palpable wave transmission occurs when the
valves are incompetent. Competent veins will prevent a wave transmission and the
nurse's distal (lower) fingers will feel no change. The test is performed while the patient
is standing.
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 a left-sided mastectomy 1 year ago. The nurse suspects which
problem?
A)
, Venous stasis
B)
Lymphedema
C)
Arteriosclerosis
D)
Deep vein thrombosis - - correct ans- -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 it can impede drainage of lymph. The other responses are not correct.
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which
statement about the ABI is true?
A)
Normal ABI indices are from 0.50 to 1.0.
B)
The normal ankle pressure is slightly lower than the brachial pressure.
C)
The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals.
D)
An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild
claudication. - - correct ans- -ANS: D
Use of the Doppler stethoscope is a noninvasive way to determine the extent of
peripheral vascular disease. The normal ankle pressure is slightly greater than or equal
to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral
vascular disease and mild claudication. The ABI is less reliable in patients with diabetes
mellitus because of claudication, which makes the arteries noncompressible and may
give a falsely high ankle pressure.
