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Health Assessment 2 (NR 304) Examinations with verified answers

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Health Assessment 2 (NR 304) Examinations with verified answers

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Advanced education

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Health Assessment 2 (NR 304) Examinations
with verified answers


palpation of radial pulse - ANSWERPalpate both pulses noting the rate,
rhythm, elasticity of vessel wall and equal force



grading pulse - ANSWER3+ full bounding

2+ normal

1+ weak

0 absent



brachial pulse - ANSWERpalpate this pulse if you suspect arterial insufficiency



modified Allen's test - ANSWERtests 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 - ANSWERpalpated in front of the ear



carotid artery - ANSWERpalpated in the groove b/t the sternomastoid muscle
and the trachea

,brachial artery - ANSWERmajor artery supplying the arm



radial artery - ANSWERlies medial to the radius and wrist supplies blood to
the hand



ulnar artery - ANSWERlies lateral to the ulna. Deeper and often difficult to
feel. Supplies blood to the hand



femoral artery - ANSWERmajor artery in the leg. Palpated in the inguinal area



popliteal artery - ANSWERartery in the knee. Located posterior to the patella.
Divides into the anterior and posterial tibial artery



anterior tibial - ANSWERtravels 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 - ANSWERtravels 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 - ANSWERa blood vessel of the lower limb that carries
oxygenated blood to the dorsal surface of the foot

,claudication distance - ANSWERthe number of blocks walked or stairs
climbed to produce pain



arterial claudication - ANSWERpain in the calf, thigh or hip or muscle fatigue
that occurs when walking a certain distance related to peripheral arterial
disease (PAD)



peripheral perfusion - ANSWERchecking for capillary refill by blanching the
nail beds and noting the time for color return

normal is less than 1-2 seconds



doppler - ANSWERused 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 - ANSWERfluid build up in the interstitial space



PVD - ANSWERcirculation 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 - ANSWERswelling in the arms or legs caused by a blockage of
the lymphatic system , causes a build up of lymph fluid in tissues

, intermittent claudication - ANSWERa condition in which cramping pain in the
leg is induced by exercise, typically caused by obstruction of the arteries



5 P's - ANSWERPain

Pulselessness

Pallor

Parasthesia (can't feel)

Paralysis (can't move)



Grading Edema - 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 - ANSWER-5 P's

-Mottling

- Bluish/cyanosis

- decrease capillary refill

- cold temperature



arterial insufficiency - ANSWER- skin is cool

-skin is thin and shiny

- no edema

-no hair growth

- decreased pulses

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