NR 304 Health Assessment II Final Exam: Questions &
Correct Explanations
Palpation of radial pulse Correct Answer - Palpate both pulses noting the
rate, rhythm, elasticity of vessel wall and equal force
Grading pulse Correct Answer - 3+ full bounding
2+ normal
1+ weak
0 absent
Brachial pulse Correct Answer - palpate this pulse if you suspect arterial
insufficiency
Modified Allen's test Correct Answer - tests for ulnar arterial
insufficiency by occluding both the radial and ulnar artery
normal results: normal color of hand should reappear approximately 2-5
seconds
abnormal results: pallor persists or a sluggish return to color suggest
occlusion of the collateral arterial flow
Temporal artery Correct Answer - palpated in front of the ear
Carotid artery Correct Answer - palpated in the groove b/t the
sternomastoid muscle and the trachea
Brachial artery Correct Answer - major artery supplying the arm
Radial artery Correct Answer - lies medial to the radius and wrist
supplies blood to the hand
Ulnar artery Correct Answer - lies lateral to the ulna. Deeper and often
difficult to feel. Supplies blood to the hand
Femoral artery Correct Answer - major artery in the leg. Palpated in the
inguinal area
,Popliteal artery Correct Answer - artery in the knee. Located posterior
to the patella. Divides into the anterior and posterial tibial artery
Anterior tibial Correct Answer - travels down the front of the leg on to
the dorsal of the foot becomes the dorsalis pedis.
carries blood to the anterior compartment of the leg and dorsal surface of the
foot
Posterior tibial Correct Answer - travels down behind the medial
malleolus and forms the plantar arteries in the foot.
carries blood to the posterior compartment of the leg and plantar surface of
the foot
Dorsalis pedis Correct Answer - a blood vessel of the lower limb that
carries oxygenated blood to the dorsal surface of the foot
Claudication distance Correct Answer - the number of blocks walked or
stairs climbed to produce pain
arterial claudication Correct Answer - pain in the calf, thigh or hip or
muscle fatigue that occurs when walking a certain distance related to
peripheral arterial disease (PAD)
Peripheral perfusion Correct Answer - checking for capillary refill by
blanching the nail beds and noting the time for color return
normal is less than 1-2 seconds
doppler Correct Answer - used if pulses are too weak to detect by
palpation, monitor blood pressure in infants or children, measure low blood
pressure or blood pressure in the lower extremities
A noninvasive test using sound waves to detect blood flow through blood
vessels
ex. competent valves (varicosities)
Edema Correct Answer - fluid build up in the interstitial space
PVD Correct Answer - circulation disorder in which narrowed blood
vessels reduce blood flow to the limbs. Caused by arteriosclerosis (hardening
of arteries caused by plaque build up)
, Inspect skin for ulcers, temperature and color
Lymphedema Correct Answer - swelling in the arms or legs caused by a
blockage of the lymphatic system , causes a build up of lymph fluid in tissues
Intermittent claudication Correct Answer - a condition in which
cramping pain in the leg is induced by exercise, typically caused by
obstruction of the arteries
5 P's Correct Answer - Pain
Pulselessness
Pallor
Parasthesia (can't feel)
Paralysis (can't move)
Grading Edema Correct Answer - +1 mild pitting, no swelling
+2 moderate pulling, indentation goes away quickly
+3 deep pitting, swollen
+4 very deep pitting, indentation stays, very swollen
Arterial Occlusion Correct Answer - -5 P's
-Mottling
- Bluish/cyanosis
- decrease capillary refill
- cold temperature
Arterial insufficiency Correct Answer - - skin is cool
-skin is thin and shiny
- no edema
-no hair growth
- decreased pulses
-yellow toenails
-dependent rubor (ruddy red/blue)
-elevated pallor
Venous insufficiency Correct Answer - - normal temperature
-normal pulse
-flaky, dry, thick skin
-skin tears easily- friable
Correct Explanations
Palpation of radial pulse Correct Answer - Palpate both pulses noting the
rate, rhythm, elasticity of vessel wall and equal force
Grading pulse Correct Answer - 3+ full bounding
2+ normal
1+ weak
0 absent
Brachial pulse Correct Answer - palpate this pulse if you suspect arterial
insufficiency
Modified Allen's test Correct Answer - tests for ulnar arterial
insufficiency by occluding both the radial and ulnar artery
normal results: normal color of hand should reappear approximately 2-5
seconds
abnormal results: pallor persists or a sluggish return to color suggest
occlusion of the collateral arterial flow
Temporal artery Correct Answer - palpated in front of the ear
Carotid artery Correct Answer - palpated in the groove b/t the
sternomastoid muscle and the trachea
Brachial artery Correct Answer - major artery supplying the arm
Radial artery Correct Answer - lies medial to the radius and wrist
supplies blood to the hand
Ulnar artery Correct Answer - lies lateral to the ulna. Deeper and often
difficult to feel. Supplies blood to the hand
Femoral artery Correct Answer - major artery in the leg. Palpated in the
inguinal area
,Popliteal artery Correct Answer - artery in the knee. Located posterior
to the patella. Divides into the anterior and posterial tibial artery
Anterior tibial Correct Answer - travels down the front of the leg on to
the dorsal of the foot becomes the dorsalis pedis.
carries blood to the anterior compartment of the leg and dorsal surface of the
foot
Posterior tibial Correct Answer - travels down behind the medial
malleolus and forms the plantar arteries in the foot.
carries blood to the posterior compartment of the leg and plantar surface of
the foot
Dorsalis pedis Correct Answer - a blood vessel of the lower limb that
carries oxygenated blood to the dorsal surface of the foot
Claudication distance Correct Answer - the number of blocks walked or
stairs climbed to produce pain
arterial claudication Correct Answer - pain in the calf, thigh or hip or
muscle fatigue that occurs when walking a certain distance related to
peripheral arterial disease (PAD)
Peripheral perfusion Correct Answer - checking for capillary refill by
blanching the nail beds and noting the time for color return
normal is less than 1-2 seconds
doppler Correct Answer - used if pulses are too weak to detect by
palpation, monitor blood pressure in infants or children, measure low blood
pressure or blood pressure in the lower extremities
A noninvasive test using sound waves to detect blood flow through blood
vessels
ex. competent valves (varicosities)
Edema Correct Answer - fluid build up in the interstitial space
PVD Correct Answer - circulation disorder in which narrowed blood
vessels reduce blood flow to the limbs. Caused by arteriosclerosis (hardening
of arteries caused by plaque build up)
, Inspect skin for ulcers, temperature and color
Lymphedema Correct Answer - swelling in the arms or legs caused by a
blockage of the lymphatic system , causes a build up of lymph fluid in tissues
Intermittent claudication Correct Answer - a condition in which
cramping pain in the leg is induced by exercise, typically caused by
obstruction of the arteries
5 P's Correct Answer - Pain
Pulselessness
Pallor
Parasthesia (can't feel)
Paralysis (can't move)
Grading Edema Correct Answer - +1 mild pitting, no swelling
+2 moderate pulling, indentation goes away quickly
+3 deep pitting, swollen
+4 very deep pitting, indentation stays, very swollen
Arterial Occlusion Correct Answer - -5 P's
-Mottling
- Bluish/cyanosis
- decrease capillary refill
- cold temperature
Arterial insufficiency Correct Answer - - skin is cool
-skin is thin and shiny
- no edema
-no hair growth
- decreased pulses
-yellow toenails
-dependent rubor (ruddy red/blue)
-elevated pallor
Venous insufficiency Correct Answer - - normal temperature
-normal pulse
-flaky, dry, thick skin
-skin tears easily- friable
