Chamberlain University
NR-304: Health
Assessment II
Comprehensive Exam
Instructions: Read each question carefully and select the best
answer. The correct answer is bolded and followed by a
rationale.
Section 1: Peripheral Vascular System
1. A nurse is assessing a client for arterial insufficiency. Which
of the following findings is consistent with this condition?
a. Edema that is pitting and bilateral
b. Skin that is shiny, hairless, and thin
c. Ulcers with irregular edges located around the medial
malleolus
d. Pulses that are 2+ and bounding
Rationale: Arterial insufficiency causes trophic skin changes
including shiny, hairless, thin skin with thickened nails. Edema
,and ulcers around the medial malleolus are characteristic of
venous insufficiency .
2. A nurse is assessing a client's lower extremities and notes
2+ pitting edema. Which condition is most commonly
associated with pitting edema?
a. Arterial insufficiency
b. Venous insufficiency
c. Raynaud's phenomenon
d. Buerger's disease
Rationale: Pitting edema is a hallmark sign of venous
insufficiency due to fluid accumulation from poor venous
return. Arterial insufficiency typically does not cause edema .
3. A nurse is assessing a client for deep vein thrombosis (DVT).
Which finding is most concerning?
a. Unilateral calf pain and swelling
b. Bilateral ankle edema
c. Warm, dry skin
d. Capillary refill of 2 seconds
Rationale: Unilateral calf pain and swelling is a classic sign of
DVT. Bilateral edema is more consistent with systemic issues
such as heart failure .
4. Virchow's triad consists of which three factors that
contribute to DVT formation?
,a. Hypertension, hyperlipidemia, and diabetes
b. Venous stasis, endothelial damage, and hypercoagulability
c. Smoking, obesity, and immobility
d. Infection, inflammation, and dehydration
Rationale: Virchow's triad includes venous stasis, endothelial
damage, and hypercoagulability—the three primary factors
contributing to thrombus formation .
5. A nurse is assessing a client's peripheral pulses and
documents a 1+ pulse. How should the nurse interpret this
finding?
a. Absent pulse
b. Weak, thready pulse
c. Normal pulse
d. Bounding pulse
Rationale: Pulse force is graded on a scale of 0 to 4+: 0 =
absent, 1+ = weak/thready, 2+ = normal, 3+ = increased, 4+ =
full/bounding .
6. A patient reports leg pain that occurs when walking and is
relieved by rest. This is consistent with:
a. Neuropathic pain
b. Intermittent claudication
c. Rest pain
d. Muscle cramps
, Rationale: Intermittent claudication is pain in the legs that
occurs with exercise and is relieved by rest. It is a classic
symptom of peripheral arterial disease .
7. A patient with peripheral arterial disease is at risk for which
complication?
a. Skin breakdown and ulceration
b. Pulmonary embolism
c. Stroke
d. Myocardial infarction
Rationale: Peripheral arterial disease can lead to skin
breakdown, ulceration, and tissue necrosis due to inadequate
blood flow to the extremities .
8. A patient reports leg pain that worsens with dependency
and is relieved by elevation. The nurse notes brown
pigmentation and edema in the lower legs. Which condition
should the nurse suspect?
a. Arterial insufficiency
b. Venous insufficiency
c. Deep vein thrombosis
d. Cellulitis
Rationale: Venous insufficiency causes aching pain that worsens
with dependency and is relieved by elevation. Brown
pigmentation (hemosiderin staining) and edema are
characteristic .
NR-304: Health
Assessment II
Comprehensive Exam
Instructions: Read each question carefully and select the best
answer. The correct answer is bolded and followed by a
rationale.
Section 1: Peripheral Vascular System
1. A nurse is assessing a client for arterial insufficiency. Which
of the following findings is consistent with this condition?
a. Edema that is pitting and bilateral
b. Skin that is shiny, hairless, and thin
c. Ulcers with irregular edges located around the medial
malleolus
d. Pulses that are 2+ and bounding
Rationale: Arterial insufficiency causes trophic skin changes
including shiny, hairless, thin skin with thickened nails. Edema
,and ulcers around the medial malleolus are characteristic of
venous insufficiency .
2. A nurse is assessing a client's lower extremities and notes
2+ pitting edema. Which condition is most commonly
associated with pitting edema?
a. Arterial insufficiency
b. Venous insufficiency
c. Raynaud's phenomenon
d. Buerger's disease
Rationale: Pitting edema is a hallmark sign of venous
insufficiency due to fluid accumulation from poor venous
return. Arterial insufficiency typically does not cause edema .
3. A nurse is assessing a client for deep vein thrombosis (DVT).
Which finding is most concerning?
a. Unilateral calf pain and swelling
b. Bilateral ankle edema
c. Warm, dry skin
d. Capillary refill of 2 seconds
Rationale: Unilateral calf pain and swelling is a classic sign of
DVT. Bilateral edema is more consistent with systemic issues
such as heart failure .
4. Virchow's triad consists of which three factors that
contribute to DVT formation?
,a. Hypertension, hyperlipidemia, and diabetes
b. Venous stasis, endothelial damage, and hypercoagulability
c. Smoking, obesity, and immobility
d. Infection, inflammation, and dehydration
Rationale: Virchow's triad includes venous stasis, endothelial
damage, and hypercoagulability—the three primary factors
contributing to thrombus formation .
5. A nurse is assessing a client's peripheral pulses and
documents a 1+ pulse. How should the nurse interpret this
finding?
a. Absent pulse
b. Weak, thready pulse
c. Normal pulse
d. Bounding pulse
Rationale: Pulse force is graded on a scale of 0 to 4+: 0 =
absent, 1+ = weak/thready, 2+ = normal, 3+ = increased, 4+ =
full/bounding .
6. A patient reports leg pain that occurs when walking and is
relieved by rest. This is consistent with:
a. Neuropathic pain
b. Intermittent claudication
c. Rest pain
d. Muscle cramps
, Rationale: Intermittent claudication is pain in the legs that
occurs with exercise and is relieved by rest. It is a classic
symptom of peripheral arterial disease .
7. A patient with peripheral arterial disease is at risk for which
complication?
a. Skin breakdown and ulceration
b. Pulmonary embolism
c. Stroke
d. Myocardial infarction
Rationale: Peripheral arterial disease can lead to skin
breakdown, ulceration, and tissue necrosis due to inadequate
blood flow to the extremities .
8. A patient reports leg pain that worsens with dependency
and is relieved by elevation. The nurse notes brown
pigmentation and edema in the lower legs. Which condition
should the nurse suspect?
a. Arterial insufficiency
b. Venous insufficiency
c. Deep vein thrombosis
d. Cellulitis
Rationale: Venous insufficiency causes aching pain that worsens
with dependency and is relieved by elevation. Brown
pigmentation (hemosiderin staining) and edema are
characteristic .
