HESI Case Study: Peripheral Vascular and Lymphatics Questions & Answers

The RN prepares to complete a history and physical assessment. Ms. Empanio ask the RN to call her Lourdes. 1. The RN reviews Lourdes' initial complaint that her feet feel numb. What assessment should the RN perform first? -palpate the dorsalis pedis pulses -Locate the inguinal lymph nose -Measure toenail capillary refill -compare calf circumferences - ANSWERSPalpate the dorsalis pedal pulses. {Because the client has complained of numbness it is important to asses for the presence and strength of the pedal pulses, a measure of the arterial circulation to the feet. The acute absence of arterial circulation would require immediate intervention. The RN palpates the dorsalis pedis pulses bilaterally and determines the both pulses are weak and thready 2. What additional assessment information will validate this finding? -Pale, cool skin -Flushed, moist skin -Inflamed, hot skin -Dry, inelastic skin - ANSWERS-Pale cool skin Lourdes feet are pale and cool to the touch, consistent with the weak, thready pedal pulses palpated by the RN. The RNS uses a Doppler Ultrasound stethoscope to confirm the presence of the dorsalis pedis pulses. After applying get to the transducer and placing the transducer over the middle of the dorsal surface of the foot, the RN hears a regular swooshing sound. 3. What action should the RN take? -Document the presence of the pulse heard by Doppler Ultrasound -Notify the HCP immediately of the lack of pulse -Move the end of the transducer closer to the toes and listen again -Removed the excess gel, apply pressure more gently and try again - ANSWERS-Document the presence of the pulse heard by Doppler Ultrasound The wound Lourdes mentioned is located on the plantar surface of her right foot, on the ball of the foot. The RN observes the wound bed is red and the tissue immediately surrounding the wound is inflamed. The RN plans to document the stage of the wound. 4. What additional action should the RN take to correctly stage the wound? -Observe the tissue to determine the phase of wound healing -Determine the depth of the wound and underlying tissue damage -Note the amount, color and character of the wound drainage -Measure the width of the wound from front to back and side to side - ANSWERS-Determine the depth of the wound and underlying tissue damage The RN determines that Lourdes' wound is a stage II pressure ulcer. 5. The RN notes that the wound is round and 0.5cm in diameter. To assess for the presence of any undermining tracts, what action should the RN implement? -Gently irrigate the wound with sterile saline to help determine the depth -Insert a sterile, cotton-tipped applicator to measure the depth -Note the amount and appearance of any drainage to help determine the depth -Use sterile forceps to apply sterile packing to help determine the depth - ANSWERS-Insert a sterile, cotton-tipped applicator to measure the depth After completing the focused assessment of Lourdes' pedal pulses, the wound on the bottom of her foot and Lourdes' subjective report of the numbness, the rN begins to obtain the client's history, focusing on data related to her peripheral vascular system. 6. To learn about any history of intermittent claudication, what question should the RN ask? -"When you first stand up, do you feel dizzy or light-headed?" -"Have you experienced any leg cramping or pain in your legs? -"Can you feel your pulse pounding after vigorous activity?" -"Do you have an urge to move your legs a lot during the night?" - ANSWERS-"Have you experienced any leg cramping or pain in your legs? A client reports that she often experiences leg cramps, usually after walking around the park. 7. What follow-up question by the RN provides the best information about the client's claudication distance? -"when did you first notice you were having leg cramps?" -"How long have you been walking this same distance?" -"How far do you walk before the leg cramps begin?" -"On a 10-point scale, how would you rank your pain?" - ANSWERS-"How far do you walk before the leg cramps begin?" 8. The RN has already observed that both of Lourdes' feet are cool and pale. What questions should the RN ask Lourdes to obtain additional supporting data? (select all that apply) -"Are any of your veins bulging or crooked?" -"Do you feel tingling, numbness, or burning sensation in your legs and feet?" -"Have you ever had a blood clot?" -"Do your toes or toenails ever look blue?" -"After a bump, do you bruise easily?" - ANSWERS-"Do you feel tingling, numbness, or burning sensation in your legs and feet?" -"Do your toes or toenails ever look blue?" The RN begins the assessment at the client's inguinal area, assessing the femoral artery and the inguinal lymph nodes. The RN palpates the femoral artery and notes that it is weak. The RN decides to assess for the presence of a bruit. 9. What action should the RN take? -Position a stethoscope over the artery -Observe the site for bulges or swelling -Firmly compress the artery with the fingertips -Feel the inguinal area with the back of the hand. - ANSWERS-Position a stethoscope over the artery 10. After assessing the femoral artery, the RN palpates the inguinal lymph nodes. What technique should be used? -firmly compress the area until blanching occurs and then release. -Move the finger pads over the area using a gentle circular motion -Gently press downward with the fingertips until the node is felt -Lightly press the palmar surface of one hand over the inguinal area - ANSWERS-Move the finger pads over the area using a gentle circular motion 11. During the health history, Lourdes reported that her feet and ankles swell occasionally. To assess for edema, what action the RN take first? -Ask the client to lie down and elevate her feet and legs -Ask the client to gently dorsiflex each of her feet -Observe and compare the client's lower extremities -Gently compress the tissue on the top of the client's feet - ANSWERS-Observe and compare the client's lower extremities 12. Although there is no visible swelling, Lourdes' legs are large, so the RN gently depresses the tissue over the tibia for one second, noting that the tissue bounces back immediately. What action should the RN take next? -Ask the client to elevate her legs and repeat -Compress the tissue more firmly for 5 seconds -Note that there is currently no edema present -Document the presence of non-pitting edema - ANSWERS-Compress the tissue more firmly for 5 seconds The RN's assessment reveals that the valves are competent, and the RN continues the assessment. While Lourdes is standing, the RN notes the absence of any dependent rubor.