NR 509 WEEK 4 Midterm EXAM

1. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. - ANS: brachial 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. 2. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? - ANS: Lateral to the extensor tendon of the great toe 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. There is no pulse palpated at the lateral malleolus. 3. Which of these veins are responsible for most of the venous return in the arm? - ANS: Superficial The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return. 4. The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? - ANS: Person who has been on bed rest for 4 days At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy. 5. When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? - ANS: Examine the patient's lower arm and hand, and check for the presence of infection or lesions. 6. 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. 7. 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? - ANS: Enlarged and tender inguinal nodes 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. 8. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? - ANS: Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct 9. A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: - ANS: claudication. Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes. The other responses are not correct. 10. A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: - ANS: problems related to arterial insufficiency. Night leg pain is common in aging adults. It 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. 11. The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? - ANS: Consider this a delayed capillary refill time and investigate further. 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. 12. When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? - ANS: Auscultate the site for a bruit. If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct. 13. 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. The nurse should next: - ANS: consider this a normal finding and proceed with the peripheral vascular evaluation. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct. 14. The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. - ANS: bounding A full, bounding pulse occurs with hyperkinetic states (such as exercise, anxiety, fever), anemia, and hyperthyroidism. Absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease. 15. A patient has a positive Homans' sign. The nurse knows that a positive Homans' sign may indicate: - ANS: deep vein thrombosis. Calf pain on dorsiflexion of the foot is a positive Homans' sign, which occurs in about 35% of deep vein thromboses. It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury. 16. A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? - ANS: A brownish discoloration to the skin of the lower leg A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems. 17. The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? - ANS: Ask the patient to bend his or her knees to the side in a froglike position.