1
NR 304 Exam 1 (Latest Update) Health
Assessment II | Questions & Answers | 100%
Correct | Grade A+ | Chamberlain
EXAM 1 (Ch. 21 & 22)
1. Signs oƒ DVT (clinical maniƒestations) – 2 questions
○ Unilateral swelling oƒ the aƒƒected leg
○ Tenderness to severe pain
○ Possibly warmth & redness (accompanying inƒlammation)
○ Possibly superƒicial venous dilation
2. Eƒƒects oƒ smoking
○ Bilateral cool ƒeet
○ Strongest risk ƒor peripheral vascular disease
○ Risk ƒor arterial ulcers
○ Risk ƒor atherosclerosis
3. Assessing peripheral blood ƒlow
○ Modiƒied Allen Test → → →
○ Doppler
○ Capillary reƒill
4. Peripheral vascular system assessment ƒor diƒƒerent age groups
○ Inƒants & Children (normal vs. abnormal ƒindings)
Transient acrocyanosis & skin mottling at birth Weak pulses occur with vasoconstriction oƒ
Pulse ƒorce should be normal & symmetric diminished CO
Ƒorce should be same in upper & lower Ƒull, bounding pulses occur with patent
extremities ductus arteriosus ƒrom the large leƒt-to-right
shunt Diminished or absent ƒemoral pulses
but normal upper-extremity pulses suggest
coarctation oƒ aorta
Palpable lymph nodes occur oƒten (healthy) Enlarged, warm, tender nodes indicate current
They are small, ƒirm (shotty), mobile, inƒection
nontender May be sequelae oƒ past Look ƒor source oƒ inƒection
inƒections
Vaccinations can produce local
lymphadenopathy Note characteristics oƒ
palpable nodes (local/generalized)
○ Pregnanacy (normal vs. abnormal ƒindings)
Expect diƒƒuse bilateral pitting edema in lower extremities, Remain alert ƒor generalized edema, plus
especially at the end oƒ the day & into 3rd trimester hypertension, which suggests preeclampsia,
Nearly 80% oƒ pregnant women have some peripheral edema a dangerous obstretric condition
because oƒ increased water retention
Varicose veins in legs also common in 3rd trimester
, 2
○ Older adults (normal ƒindings)
■ The dorsalis pedis & posterior tibial pulses may become more diƒƒicult to ƒind
■ Trophic changes associated with arterial insuƒƒiciency
● Thin, shiny skin
● Thick-ridged nails
● Loss oƒ hair on legs
5. Why/how would you use a Doppler?
○ Why?
■ Doppler ƒlow studies can ensure collateral ƒlow that is quantiƒiable
, 3
■ To detect a weak peripheral pulse
■ To monitor BP in inƒants or children
■ To measure a low BP or BP in a lower extremity
○ How?
■ Probe magniƒies sounds ƒrom the heart & blood vessels
■ Position the person supine, with legs externally rotated so you can reach medial ankles easily
■ Place a drop oƒ coupling gel on the end oƒ the handheld transducer
■ Place transducer over a pulse site at about a 90-degree angle
■ Apply very light pressure & located the pulse site by the swishing, whooshing sound
6. Signs oƒ PAD
○ Ankle-Brachial Index (ABI) oƒ 0.90 or less
■ 0.90 - 0.71 → mild PAD
■ 0.70 - 0.41 → moderate PAD
■ 0.40 - 0.30 → severe PAD
○ Pain Proƒiles
■ Location
● Deep muscle pain (usually in calƒ, but may be lower leg or dorsum oƒ ƒoot)
■ Character
● Intermittent claudication (ƒeels like “cramp,” “numbness & tingling,” or “ƒeeling oƒ
cold”)
■ Onset & duration
● Chronic pain, onset gradual aƒter exertion
■ Aggravating ƒactors
● Activity (walking, stairs)
○ “Claudication distance” → speciƒic number oƒ blocks, stairs it takes to produce
pain
● Elevation (rest pain indicates severe involvement)
■ Relieving ƒactors
● Rest (usually within 2 minutes)
● Dangling (severe involvement)
■ Associated symptoms
● Low ankle-brachial index
● Cool, pale skin
● Diminished pulses, pallor on elevation
○ Signs
■ Arteriosclerosis (peripheral blood vessels more rigid)
■ Atherosclerosis (deposition oƒ ƒatty plaques on intima oƒ arteries)
■ Poor wound healing
■ Intermittent claudication (leg cramping when walking)
■ Ischemic rest pain
■ Coolness
■ Weak, “thready” pulse (1+)
, 4
7. Priority nursing diagnosis & physical ƒindings – varicose veins
○ Nursing Diagnosis → chronic increased venous pressure OR incompetent valves
○ Physical ƒindings
■ Subjective
● Aching
● Heaviness in calƒ
● Easy ƒatiguability
● Restless legs
● Burning
● Throbbing
● Cramping
■ Objective
● Dilated, tortuous veins
8. Grading peripheral edema
○ 0 → no pitting
○ 1+ → mild pitting, slight indentation, no perceptible swelling oƒ the leg
○ 2+ → moderate pitting, indentation subsides rapidly
○ 3+ → deep pitting, indentation remains ƒor a short time, leg looks swollen
○ 4+ → very deep pitting, indentation lasts a long time, leg is grossly swollen & distorted
9. Nursing care r/t DVT
○ Inspect & palpate the legs → iƒ DVT is suspected
■ Measure the calƒ circumƒerence with a non-stretchable tape measure
● Acute, unilateral, painƒul swelling & asymmetry (≥ 1 cm) oƒ calves, reƒer to determine
iƒ DVT
■ Measure at the widest point, taking care to measure the other leg in exactly the same place
○ Many assessment ƒindings are unreliable & also occur with other conditions → Wells Score ƒor Leg DVT
■ Clinical Model ƒor Predicting Pretest Probability oƒ DVT
Clinical Characteristic Score
Active cancer (treatment ongoing, administered within previous 6 months or palliative) 1
Paralysis, paresis, or recent plaster immobilization oƒ the lower extremities 1
Recently bedridden > 3 days or major surgery within previous 12 weeks requiring general or regional 1
anesthesia
Localized tenderness along the distribution oƒ the deep venous system 1
Swelling oƒ entire leg 1
Calƒ swelling > 3 cm larger than the asymptomatic side (measured 10 cm below tibial tuberosity) 1
Pitting edema conƒined to the symptomatic leg 1
Collateral superƒicial veins (nonvaricose) 1
Previously documented DVT 1
NR 304 Exam 1 (Latest Update) Health
Assessment II | Questions & Answers | 100%
Correct | Grade A+ | Chamberlain
EXAM 1 (Ch. 21 & 22)
1. Signs oƒ DVT (clinical maniƒestations) – 2 questions
○ Unilateral swelling oƒ the aƒƒected leg
○ Tenderness to severe pain
○ Possibly warmth & redness (accompanying inƒlammation)
○ Possibly superƒicial venous dilation
2. Eƒƒects oƒ smoking
○ Bilateral cool ƒeet
○ Strongest risk ƒor peripheral vascular disease
○ Risk ƒor arterial ulcers
○ Risk ƒor atherosclerosis
3. Assessing peripheral blood ƒlow
○ Modiƒied Allen Test → → →
○ Doppler
○ Capillary reƒill
4. Peripheral vascular system assessment ƒor diƒƒerent age groups
○ Inƒants & Children (normal vs. abnormal ƒindings)
Transient acrocyanosis & skin mottling at birth Weak pulses occur with vasoconstriction oƒ
Pulse ƒorce should be normal & symmetric diminished CO
Ƒorce should be same in upper & lower Ƒull, bounding pulses occur with patent
extremities ductus arteriosus ƒrom the large leƒt-to-right
shunt Diminished or absent ƒemoral pulses
but normal upper-extremity pulses suggest
coarctation oƒ aorta
Palpable lymph nodes occur oƒten (healthy) Enlarged, warm, tender nodes indicate current
They are small, ƒirm (shotty), mobile, inƒection
nontender May be sequelae oƒ past Look ƒor source oƒ inƒection
inƒections
Vaccinations can produce local
lymphadenopathy Note characteristics oƒ
palpable nodes (local/generalized)
○ Pregnanacy (normal vs. abnormal ƒindings)
Expect diƒƒuse bilateral pitting edema in lower extremities, Remain alert ƒor generalized edema, plus
especially at the end oƒ the day & into 3rd trimester hypertension, which suggests preeclampsia,
Nearly 80% oƒ pregnant women have some peripheral edema a dangerous obstretric condition
because oƒ increased water retention
Varicose veins in legs also common in 3rd trimester
, 2
○ Older adults (normal ƒindings)
■ The dorsalis pedis & posterior tibial pulses may become more diƒƒicult to ƒind
■ Trophic changes associated with arterial insuƒƒiciency
● Thin, shiny skin
● Thick-ridged nails
● Loss oƒ hair on legs
5. Why/how would you use a Doppler?
○ Why?
■ Doppler ƒlow studies can ensure collateral ƒlow that is quantiƒiable
, 3
■ To detect a weak peripheral pulse
■ To monitor BP in inƒants or children
■ To measure a low BP or BP in a lower extremity
○ How?
■ Probe magniƒies sounds ƒrom the heart & blood vessels
■ Position the person supine, with legs externally rotated so you can reach medial ankles easily
■ Place a drop oƒ coupling gel on the end oƒ the handheld transducer
■ Place transducer over a pulse site at about a 90-degree angle
■ Apply very light pressure & located the pulse site by the swishing, whooshing sound
6. Signs oƒ PAD
○ Ankle-Brachial Index (ABI) oƒ 0.90 or less
■ 0.90 - 0.71 → mild PAD
■ 0.70 - 0.41 → moderate PAD
■ 0.40 - 0.30 → severe PAD
○ Pain Proƒiles
■ Location
● Deep muscle pain (usually in calƒ, but may be lower leg or dorsum oƒ ƒoot)
■ Character
● Intermittent claudication (ƒeels like “cramp,” “numbness & tingling,” or “ƒeeling oƒ
cold”)
■ Onset & duration
● Chronic pain, onset gradual aƒter exertion
■ Aggravating ƒactors
● Activity (walking, stairs)
○ “Claudication distance” → speciƒic number oƒ blocks, stairs it takes to produce
pain
● Elevation (rest pain indicates severe involvement)
■ Relieving ƒactors
● Rest (usually within 2 minutes)
● Dangling (severe involvement)
■ Associated symptoms
● Low ankle-brachial index
● Cool, pale skin
● Diminished pulses, pallor on elevation
○ Signs
■ Arteriosclerosis (peripheral blood vessels more rigid)
■ Atherosclerosis (deposition oƒ ƒatty plaques on intima oƒ arteries)
■ Poor wound healing
■ Intermittent claudication (leg cramping when walking)
■ Ischemic rest pain
■ Coolness
■ Weak, “thready” pulse (1+)
, 4
7. Priority nursing diagnosis & physical ƒindings – varicose veins
○ Nursing Diagnosis → chronic increased venous pressure OR incompetent valves
○ Physical ƒindings
■ Subjective
● Aching
● Heaviness in calƒ
● Easy ƒatiguability
● Restless legs
● Burning
● Throbbing
● Cramping
■ Objective
● Dilated, tortuous veins
8. Grading peripheral edema
○ 0 → no pitting
○ 1+ → mild pitting, slight indentation, no perceptible swelling oƒ the leg
○ 2+ → moderate pitting, indentation subsides rapidly
○ 3+ → deep pitting, indentation remains ƒor a short time, leg looks swollen
○ 4+ → very deep pitting, indentation lasts a long time, leg is grossly swollen & distorted
9. Nursing care r/t DVT
○ Inspect & palpate the legs → iƒ DVT is suspected
■ Measure the calƒ circumƒerence with a non-stretchable tape measure
● Acute, unilateral, painƒul swelling & asymmetry (≥ 1 cm) oƒ calves, reƒer to determine
iƒ DVT
■ Measure at the widest point, taking care to measure the other leg in exactly the same place
○ Many assessment ƒindings are unreliable & also occur with other conditions → Wells Score ƒor Leg DVT
■ Clinical Model ƒor Predicting Pretest Probability oƒ DVT
Clinical Characteristic Score
Active cancer (treatment ongoing, administered within previous 6 months or palliative) 1
Paralysis, paresis, or recent plaster immobilization oƒ the lower extremities 1
Recently bedridden > 3 days or major surgery within previous 12 weeks requiring general or regional 1
anesthesia
Localized tenderness along the distribution oƒ the deep venous system 1
Swelling oƒ entire leg 1
Calƒ swelling > 3 cm larger than the asymptomatic side (measured 10 cm below tibial tuberosity) 1
Pitting edema conƒined to the symptomatic leg 1
Collateral superƒicial veins (nonvaricose) 1
Previously documented DVT 1
