NR 304 Health Assessment 2 Exam 1 – Questions
Answered With Expert Insight
A nurse is palpating the dorsalis pedis pulse of a patient and finds it difficult to
locate. What is the next best action?
A. Document "absent dorsalis pedis pulse."
B. Use a Doppler ultrasound device.
C. Ask the patient to walk and reassess.
D. Notify the healthcare provider immediately. Correct Answer - B
When assessing the peripheral pulses, the nurse uses which grading scale to
document a "normal" pulse?
A. 0
B. 1+
C. 2+
D. 3+ Correct Answer - C
***A patient presents with pain in the left calf that occurs during exercise and
is relieved by rest. What condition does this most likely suggest?
A. Chronic venous insufficiency
B. Arterial occlusion
C. Intermittent claudication
D. Deep vein thrombosis Correct Answer - C.
***What is the most reliable method to assess for pitting edema?
A. Use a tape measure to determine circumference.
B. Apply firm pressure over a bony prominence for 5 seconds and release.
C. Inspect the skin for swelling and discoloration.
D. Ask the patient if they feel tightness in their legs. Correct Answer - B
A nurse observes the following signs in a patient: cold, pale extremities with
no palpable pulse. What is the priority intervention?
A. Apply a warm compress.
B. Notify the healthcare provider immediately.
C. Assess the capillary refill time.
D. Elevate the extremities above the heart. Correct Answer - B
,A nurse auscultates a bruit over the femoral artery. This finding suggests:
A. An arterial occlusion
B. A venous thrombosis
C. Turbulent blood flow
D. Normal blood flow Correct Answer - C
Which patient is at the highest risk for peripheral arterial disease (PAD)?
A. A 45-year-old who smokes and has a history of hypertension
B. A 60-year-old with a sedentary lifestyle and low HDL levels
C. A 70-year-old with a history of recurrent deep vein thrombosis
D. A 35-year-old with diabetes and chronic venous insufficiency Correct
Answer - A
****When palpating lymph nodes, a nurse documents "normal findings" if the
nodes are:
A. Nonpalpable and mobile
B. Hard, fixed, and tender
C. Soft, mobile, and nontender
D. Enlarged, firm, and warm Correct Answer - C
***A patient presents with a red, warm, and swollen left lower leg. The nurse
suspects deep vein thrombosis (DVT). What is the priority assessment?
A. Measure calf circumference.
B. Perform a Homan's sign test.
C. Assess for peripheral pulses.
D. Auscultate for bruits. Correct Answer - A
The nurse is teaching a patient about prevention of venous stasis. Which
activity is most appropriate?
A. Elevate the legs while sitting.
B. Stand for prolonged periods to strengthen veins.
C. Limit water intake to reduce edema.
D. Wear tight compression stockings. Correct Answer - A
A patient reports enlarged lymph nodes in the neck and groin that are tender
to palpation. Which cause does the nurse most likely suspect?
A. Cancerous metastasis
B. A systemic infection
C. Congenital lymphedema
, D. An allergic reaction Correct Answer - B
Which lymph nodes are most likely to drain the lower extremities?
A. Axillary
B. Inguinal
C. Submandibular
D. Cervical Correct Answer - B
***Which of the following findings is consistent with lymphedema?
A. Bilateral swelling that resolves with elevation
B. Pitting edema and dependent redness
C. Unilateral swelling without pitting
D. Generalized swelling in the hands and feet Correct Answer - C
***The nurse observes that a patient has enlarged, nontender, and fixed
supraclavicular lymph nodes. This finding suggests:
A. A local infection
B. An autoimmune disease
C. Cancerous metastasis
D. A normal variation Correct Answer - C
***A nurse is assessing a patient with suspected lymphadenopathy. What is
the priority assessment?
A. Location and size of the nodes
B. Number of nodes involved
C. Consistency and mobility of the nodes
D. Tenderness and overlying skin changes Correct Answer - C
A nurse is educating a patient about the function of the lymphatic system.
Which statement is correct?
A. "The lymphatic system is responsible for oxygen transport."
B. "It removes excess fluid from tissues and helps fight infection."
C. "It maintains blood pressure through fluid regulation."
D. "The lymphatic system produces red blood cells." Correct Answer - B
During an assessment, a nurse notes that the epitrochlear lymph nodes are
palpable. This finding suggests:
A. A systemic infection
B. Localized infection of the forearm or hand
Answered With Expert Insight
A nurse is palpating the dorsalis pedis pulse of a patient and finds it difficult to
locate. What is the next best action?
A. Document "absent dorsalis pedis pulse."
B. Use a Doppler ultrasound device.
C. Ask the patient to walk and reassess.
D. Notify the healthcare provider immediately. Correct Answer - B
When assessing the peripheral pulses, the nurse uses which grading scale to
document a "normal" pulse?
A. 0
B. 1+
C. 2+
D. 3+ Correct Answer - C
***A patient presents with pain in the left calf that occurs during exercise and
is relieved by rest. What condition does this most likely suggest?
A. Chronic venous insufficiency
B. Arterial occlusion
C. Intermittent claudication
D. Deep vein thrombosis Correct Answer - C.
***What is the most reliable method to assess for pitting edema?
A. Use a tape measure to determine circumference.
B. Apply firm pressure over a bony prominence for 5 seconds and release.
C. Inspect the skin for swelling and discoloration.
D. Ask the patient if they feel tightness in their legs. Correct Answer - B
A nurse observes the following signs in a patient: cold, pale extremities with
no palpable pulse. What is the priority intervention?
A. Apply a warm compress.
B. Notify the healthcare provider immediately.
C. Assess the capillary refill time.
D. Elevate the extremities above the heart. Correct Answer - B
,A nurse auscultates a bruit over the femoral artery. This finding suggests:
A. An arterial occlusion
B. A venous thrombosis
C. Turbulent blood flow
D. Normal blood flow Correct Answer - C
Which patient is at the highest risk for peripheral arterial disease (PAD)?
A. A 45-year-old who smokes and has a history of hypertension
B. A 60-year-old with a sedentary lifestyle and low HDL levels
C. A 70-year-old with a history of recurrent deep vein thrombosis
D. A 35-year-old with diabetes and chronic venous insufficiency Correct
Answer - A
****When palpating lymph nodes, a nurse documents "normal findings" if the
nodes are:
A. Nonpalpable and mobile
B. Hard, fixed, and tender
C. Soft, mobile, and nontender
D. Enlarged, firm, and warm Correct Answer - C
***A patient presents with a red, warm, and swollen left lower leg. The nurse
suspects deep vein thrombosis (DVT). What is the priority assessment?
A. Measure calf circumference.
B. Perform a Homan's sign test.
C. Assess for peripheral pulses.
D. Auscultate for bruits. Correct Answer - A
The nurse is teaching a patient about prevention of venous stasis. Which
activity is most appropriate?
A. Elevate the legs while sitting.
B. Stand for prolonged periods to strengthen veins.
C. Limit water intake to reduce edema.
D. Wear tight compression stockings. Correct Answer - A
A patient reports enlarged lymph nodes in the neck and groin that are tender
to palpation. Which cause does the nurse most likely suspect?
A. Cancerous metastasis
B. A systemic infection
C. Congenital lymphedema
, D. An allergic reaction Correct Answer - B
Which lymph nodes are most likely to drain the lower extremities?
A. Axillary
B. Inguinal
C. Submandibular
D. Cervical Correct Answer - B
***Which of the following findings is consistent with lymphedema?
A. Bilateral swelling that resolves with elevation
B. Pitting edema and dependent redness
C. Unilateral swelling without pitting
D. Generalized swelling in the hands and feet Correct Answer - C
***The nurse observes that a patient has enlarged, nontender, and fixed
supraclavicular lymph nodes. This finding suggests:
A. A local infection
B. An autoimmune disease
C. Cancerous metastasis
D. A normal variation Correct Answer - C
***A nurse is assessing a patient with suspected lymphadenopathy. What is
the priority assessment?
A. Location and size of the nodes
B. Number of nodes involved
C. Consistency and mobility of the nodes
D. Tenderness and overlying skin changes Correct Answer - C
A nurse is educating a patient about the function of the lymphatic system.
Which statement is correct?
A. "The lymphatic system is responsible for oxygen transport."
B. "It removes excess fluid from tissues and helps fight infection."
C. "It maintains blood pressure through fluid regulation."
D. "The lymphatic system produces red blood cells." Correct Answer - B
During an assessment, a nurse notes that the epitrochlear lymph nodes are
palpable. This finding suggests:
A. A systemic infection
B. Localized infection of the forearm or hand
