1.
When performing an assessment on a client the nurse notes the presence of an enlarged epitrochlear lymph node. The nurse would anticipate finding which of the following on the assessment?
Correct Answer
A. The forearm and hand for infection or inflammation
Explanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.
2.
When performing an assessment on a client the nurse notes the presence of an enlarged superficial inguinal nodes. The nurse would anticipate finding which of the following on the assessment?
Correct Answer
B. The lower legs for injury
Explanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.
3.
When performing an assessment on a client the nurse notes the determine circulation. The nurse would anticipate finding which of the following on the assessment?
Correct Answer
C. The equality of radial pulse
Explanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.
4.
When performing an assessment on a client the nurse notes the determine circulation to the extremities. The nurse would anticipate finding which of the following on the assessment?
Correct Answer
D. Capillary refill and temperature of the extremities
Explanation
The epitrochlear node is located on the medial surface of the arm above the elbow and drains the ulnar surface of the forearm and hand. Enlargement of lymph nodes can occur from infection, inflammation, or injury.
The superficial inguinal nodes would be assessed in relation to injury or infection of the lower legs.
The equality of the radial pulses would be assessed to determine circulation.
Capillary refill and skin temperature are used to determine circulation to the extremities, not in lymphatic assessment.
5.
When performing an assessment, the nurse notes the presence of ankle edema bilaterally. The nurse knows that:
Correct Answer
B. It is caused by blood pooling in the legs.
Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.
6.
When performing an assessment, the nurse notes the presence of inflammation and edema over the affected area. The nurse knows that:
Correct Answer
A. It is caused by an infection.
Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.
7.
When performing an assessment, the nurse notes the presence of edema in the affected extremity. The nurse knows that:
Correct Answer
C. It is caused by a blood clot in the lower leg.
Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.
8.
When performing an assessment, the nurse notes the presence of decreased pulses. The nurse knows that:
Correct Answer
D. It is caused by decreased arterial circulation.
Explanation
Problems with the lumen or valves of the leg veins can lead to stasis or pooling of blood in the veins of the lower extremities.
Infection causes inflammation and edema over the affected area and is not likely to be bilateral.
A blood clot would cause edema in the affected extremity, not bilaterally.
Decreased arterial circulation would cause decreased pulses, not edema.
9.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Which of the following should the nurse do?
Correct Answer
A. Continue with the assessment as this is a normal neonatal blood pressure reading.
Explanation
The systolic blood pressure of a newborn is 50 to 80 mm Hg; the diastolic blood pressure is 25 to 55 mm Hg. Since this is a normal finding, the nurse should continue with the assessment.
Calling the health care provider is not indicated with this normal finding.
In an infant less than one year of age, the systolic blood pressure in the thigh should equal that in the arm.
In a child over one year of age, the systolic pressure in the thigh is 10-40 mm Hg higher than that in the arm.
Another nurse does not need to validate the blood pressure since it is within normal limits.
10.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. What can the nurse tell the client about these veins?
Correct Answer
C. "This is a normal finding and is caused by pressure from your uterus delaying blood return from your legs."
Explanation
Pressure from the uterus on the lower extremities is common during pregnancy and can obstruct venous return leading to edema, varicosities of the leg, or hemorrhoids. The varicosities may not resolve after pregnancy.
This is a common finding and not cause for alarm at this point.
Notification of the health care provider is not warranted at this time.
Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.
11.
When assessing the carotid arteries, the nurse should:
Correct Answer
C. Utilize the bell of the stethoscope to assess for bruits.
Explanation
The bell of the stethoscope is used to assess for the presence of bruits.
Palpation of the carotid pulse should be firm, but not so hard that the artery is occluded.
If both carotid arteries are palpated at the same time, the result can be a drop in blood pressure or a decrease in heart rate due to stimulation of the baroreceptors.
Massage of the area should be avoided due to potential stimulation of the baroreceptors.
12.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Perform a focused assessment and call the health care provider.
Correct Answer
B. False
Explanation
Calling the health care provider is not indicated with this normal finding.
13.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Assess the thigh blood pressure expecting that it will be lower than that of the arm.
Correct Answer
B. False
Explanation
In an infant less than one year of age, the systolic blood pressure in the thigh should equal that in the arm.
14.
The neonatal(rookie) nurse obtains a newborn's blood pressure of 76/40 mm Hg. Ask another nurse to validate the blood pressure because it is low.
Correct Answer
B. False
Explanation
In a child over one year of age, the systolic pressure in the thigh is 10-40 mm Hg higher than that in the arm.
15.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "These are common and will go away after delivery."
Correct Answer
B. False
Explanation
This is a common finding and not cause for alarm at this point.
16.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "We need to talk to your health care provider about this."
Correct Answer
B. False
Explanation
Notification of the health care provider is not warranted at this time.
17.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "This is related to decreased circulation."
Correct Answer
B. False
Explanation
Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.
18.
An eight-month-pregnant client states that she has developed a few varicose veins during her pregnancy. the nurse tell the client about these veins, "This is related to decreased circulation."
Correct Answer
B. False
Explanation
Decreased circulation doesn't cause varicosities. Symptoms of decreased circulation would include cool feet and diminished pulses.
19.
When assessing the carotid arteries, the nurse should utilize the bell of the stethoscope to assess for bruits.
Correct Answer
A. True
Explanation
The bell of the stethoscope is used to assess for the presence of bruits.
20.
When assessing the carotid arteries, the nurse should palpate both carotid arteries simultaneously to assess for the symmetry of the pulse.
Correct Answer
B. False
Explanation
If both carotid arteries are palpated at the same time, the result can be a drop in blood pressure or a decrease in heart rate due to stimulation of the baroreceptors.
21.
When assessing the carotid arteries, the nurse should palpate firmly to occlude the artery.
Correct Answer
B. False
Explanation
Palpation of the carotid pulse should be firm, but not so hard that the artery is occluded.
22.
When assessing the carotid arteries, the nurse should massage the area noting any masses or hardness.
Correct Answer
B. False
Explanation
Massage of the area should be avoided due to potential stimulation of the baroreceptors.
23.
When assessing the characteristics of the pulse, the nurse notes which of the following? Select all that apply.
Correct Answer(s)
A. Rate
B. Rhythm
C. Symmetry
D. Amplitude
Explanation
Rate - the number of beats per minute.
Rhythm - the regularity of the beats.
Symmetry - pulses on both sides of the body should be equal.
Amplititude - the strength of the pulse, assessed on a 0-4+ scale.
Capillary refill - Delayed capillary refill is not a characteristic of pulse assessment.
24.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with:
Correct Answer
B. Arterial insufficiency
Explanation
Arterial insufficiency is inadequate circulation in the arterial system, which results in diminished pulses; cool, shiny skin; deep muscle pain; absence of hair on the toes; pallor on elevation; and a red color when dependent.
Venous insufficiency is inadequate circulation in the venous system due to incompetent valves in the deep veins or a blood clot in the veins. Edema is usually present. The temperature of the skin is normal.
Thrombophlebitis is inflammation of a vein with a clot.
Alterations in the lymphatic system may result in lymphedema, not alterations in the arterial circulation such as in arterial insufficiency as described above.
25.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with arterial insufficiency.
Correct Answer
A. True
Explanation
Arterial insufficiency is inadequate circulation in the arterial system, which results in diminished pulses; cool, shiny skin; deep muscle pain; absence of hair on the toes; pallor on elevation; and a red color when dependent.
26.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with venous insufficiency
Correct Answer
B. False
Explanation
Venous insufficiency is inadequate circulation in the venous system due to incompetent valves in the deep veins or a blood clot in the veins. Edema is usually present. The temperature of the skin is normal.
27.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with thrombophlebitis。
Correct Answer
B. False
Explanation
Thrombophlebitis is inflammation of a vein with a clot.
28.
A client has a 1+/0-4+ dorsalis pedis pulse on the right. The lower leg is cool, pale, and painful. This description is most consistent with lymphatic insufficiency
Correct Answer
B. False
Explanation
Alterations in the lymphatic system may result in lymphedema, not alterations in the arterial circulation such as in arterial insufficiency as described above.
29.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes:
Correct Answer
C. Decreased arterial circulation
Explanation
Pain associated with arterial insufficiency increases with exercise and is relieved with the cessation of movement.
Varicosities occur in the venous system and are not affected by exercise.
Alterations in the lymphatic system are not exacerbated by exercise.
Deep vein thrombosis is occlusion of a deep vein (e.g., blockage of the femoral vein by a blood clot). The client may have pain and edema that are present both at rest and with exercise.
30.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes decreased arterial circulation.
Correct Answer
A. True
Explanation
Pain associated with arterial insufficiency increases with exercise and is relieved with the cessation of movement.
31.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes the presence of varicosities.
Correct Answer
B. False
Explanation
Varicosities occur in the venous system and are not affected by exercise.
32.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes lymphatic abnormalities
Correct Answer
B. False
Explanation
Alterations in the lymphatic system are not exacerbated by exercise.
33.
A client tells the nurse, "My legs really hurt when I walk, but if I stop walking the pain gets better in a few minutes." This symptom most likely describes deep vein thrombosis
Correct Answer
B. False
Explanation
Deep vein thrombosis is occlusion of a deep vein (e.g., blockage of the femoral vein by a blood clot). The client may have pain and edema that are present both at rest and with exercise.
34.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to which of the following assessments?
Correct Answer
D. Arterial
Explanation
Arterial assessment includes the assessment of the temperature, texture, and moisture of the skin; assessing capillary refill; pulses; and auscultation for bruits.
Lymphatic assessment includes palpating over the various lymph node locations for tenderness or enlargement.
Respiratory assessment includes respiratory rate, auscultation of breath sounds, skin color, and capillary refill.
Venous assessment includes noting the presence of edema, varicosities, and color of the skin.
35.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to arterial.
Correct Answer
A. True
Explanation
Arterial assessment includes the assessment of the temperature, texture, and moisture of the skin; assessing capillary refill; pulses; and auscultation for bruits.
36.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to lymphatic.
Correct Answer
B. False
Explanation
Lymphatic assessment includes palpating over the various lymph node locations for tenderness or enlargement.
37.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to respiratory.
Correct Answer
B. False
Explanation
Respiratory assessment includes respiratory rate, auscultation of breath sounds, skin color, and capillary refill.
38.
Evaluation of the texture, moisture, and temperature of the skin; hair distribution; capillary refill; and auscultating for bruits are primarily related to venous.
Correct Answer
B. False
Explanation
Venous assessment includes noting the presence of edema, varicosities, and color of the skin.
39.
The nurse performs Allen's test to assess which of the following?
Correct Answer
A. Patency of the radial and ulnar arteries
Explanation
Allen's test determines the patency of the radial and ulnar arteries. To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.
Arterial assessment of the lower extremities would include assessing pulses, color, temperature, and capillary refill.
Varicose veins are assessed by inspection and palpation over the lower extremities for the presence of enlarged, distended veins.
Edema is assessed to determine its extent and whether it is pitting.
40.
The nurse performs Allen's test to assess patency of the radial and ulnar arteries.
Correct Answer
A. True
Explanation
Allen's test determines the patency of the radial and ulnar arteries.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.
41.
The nurse performs Allen's test to assess arterial circulation to the lower extremities.
Correct Answer
B. False
Explanation
Arterial assessment of the lower extremities would include assessing pulses, color, temperature, and capillary refill.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.
42.
The nurse performs Allen's test to assess varicose veins.
Correct Answer
B. False
Explanation
Varicose veins are assessed by inspection and palpation over the lower extremities for the presence of enlarged, distended veins.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.
43.
The nurse performs Allen's test to assess edema.
Correct Answer
B. False
Explanation
Edema is assessed to determine its extent and whether it is pitting.
To perform Allen's test, the nurse compresses the radial arteries as the client opens and closes the fist several times. The client then opens the hands and the nurse observes the palms, which should become pink immediately. The procedure is repeated, this time occluding the ulnar arteries and assessing the patency of the radial arteries.
44.
A client's blood pressure is 158/90 mm Hg. What does this reading suggest to the nurse?
Correct Answer
C. This client has stage 1 hypertension.
Explanation
In stage 1 hypertension, the systolic reading is between 140 to 159 mm Hg and the diastolic reading is between 90 to 99 mm Hg.
Normal blood pressure values are systolic blood pressure
45.
When performing an assessment on a client with COPD the nurse notes the presence of clubbing. Which of the following is noted in this condition? Select all that apply.
Correct Answer(s)
A. Fingertips large and round
C. Flattening of the angle of the nail
E. Base of the nail feels spongy
Explanation
Fingertips large and round - Enlargement of the tips of the fingers occurs with clubbing. Clubbing is a sign of oxygen deprivation in the extremities.
Delayed capillary refill - This is seen with circulatory problems and is not a sign of clubbing.
Flattening of the angle of the nail - This is seen with clubbing. Clubbing is a sign of oxygen deprivation in the extremities.
Delayed Allen's test - This occurs with alterations in radial and ulnar artery circulation, not clubbing.
Base of the nail feels spongy - The base of the nail feels spongy with clubbing. Clubbing is a sign of oxygen deprivation in the extremities.
46.
A client is being evaluated for suspected thrombosis of a deep leg vein. Which of the following is the nurse most likely to note during the assessment?
Correct Answer
A. Pain in the calf when dorsiflexing the foot
Explanation
Pain in the calf when dorsiflexing the foot (Homans' sign) may indicate thrombosis (blood clot) of a deep leg vein.
A cool foot with diminished pulses indicates problems with arterial circulation, not venous circulation.
Increased pain with elevation of the extremity would be present with arterial circulation abnormalities.
Decreased hair distribution on the lower legs is related to arterial abnormalities, not venous.
47.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has pain in the calf when dorsiflexing the foot.
Correct Answer
A. True
Explanation
Pain in the calf when dorsiflexing the foot (Homans' sign) may indicate thrombosis (blood clot) of a deep leg vein.
48.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has a cool foot with diminished pulses.
Correct Answer
B. False
Explanation
A cool foot with diminished pulses indicates problems with arterial circulation, not venous circulation.
49.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has increased pain with elevation of the extremity.
Correct Answer
B. False
Explanation
Increased pain with elevation of the extremity would be present with arterial circulation abnormalities.
50.
A client is being evaluated for suspected thrombosis of a deep leg vein. Client has decreased hair distribution on the legs
Correct Answer
B. False
Explanation
Decreased hair distribution on the lower legs is related to arterial abnormalities, not venous.