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The nurse is preparing to perform a peripheral vascular assessment on a
patient w/ a ulcer on the right foot. Which general principle of physical
assessment is most important for the nurse to remember in performing a
peripheral vascular assessment?
a). have patient stand upright for the physical assessment
b). palpate for skin temperature using the fingertips
c). Ensure that the stethoscope is warmed before using
d). Always compare arms and legs bilaterally - ✔✔d). Always compare
arms and legs bilateral
The nurse is performing a peripheral vascular assessment on the lower
extremities of a patient diagnosed w/ diabetes. Which assessment is
important for the nurse to include?
a). Inspect nails for fungal growth
b). Assess patellar reflexes
c). Palpate dorsalis pedis pulse
, d). Measure degree of knee flexion - ✔✔c). Palpate dorsalis pedis
The nurse is performing an assessment on the peripheral vascular system
and notes edema in one of the lower extremities. Which are causes of
unilateral edema of the lower extremities?
a). Prolonged standing position
b). Venous stasis and obstruction
c). Congestive heart failure (CHF)
d). Prolonged presence of a cast on the extremity - ✔✔b). Venous stasis
and obstruction
The nurse is assessing a patient for clinical manifestations of venous
insufficiency. Which of the following is a characteristic of venous
insufficiency?
a). Dry, shiny skin
b). Nails thickened and ridged
c). Aching, cramping pain
d). Cool-to-cold temperature - ✔✔C). Aching, cramping pain
The nurse is caring for a patient who is experiencing physical immobility
related to an acute illness. A priority nursing assessment would be to
monitor the patient for which of the following?
a). Joint contractures