Font size
WorksheetsChapter 21
Total questions: 38
Worksheet time: 20mins
Which statement is true regarding the arterial system? (pg.255)
Arteries are large-diameter vessels.
The arterial system is a high-pressure system.
The walls of arteries are thinner than those of the veins.
Arteries can greatly expand to accommodate a large blood volume increase.
The nurse is reviewing the blood supply to the arm. What major artery supplies blood to the arm? (pg.255)
Ulnar
Radial
Brachial
Deep palmar
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? (pg.255)
Behind the knee
Over the lateral malleolus
In the groove behind the medial malleolus
Lateral to the extensor tendon of the great toe
A 65-year-old patient is experiencing pain in his left calf when he exercises which disappears after resting for a few minutes. What problem in the left leg does this indicate? (pg.255)
Venous obstruction
Partial blockage of an artery
Claudication due to venous abnormalities
Ischemia caused by the complete blockage of an artery
The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? (pg.256)
Intraluminal valves ensure unidirectional flow toward the heart.
Contracting skeletal muscles milk blood distally toward the veins.
High-pressure system of the heart helps facilitate venous return.
Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
Which vein(s) is(are) responsible for most of the venous return in the arm? (pg.256)
Deep
Ulnar
Subclavain
Superficial
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, “What happens to my circulation when this vein is removed?” How should the nurse reply? (pg.256)
“Venous insufficiency is a common problem after this type of surgery.”
“Oh, you have lots of veins—you won’t even notice that it has been removed.”
“You will probably experience decreased circulation after the vein is removed.”
“This vein can be removed without harming your circulation because the deeper
The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? (pg.257)
Person who has been on bed rest for 4 days
Older adult taking anticoagulant medication
Woman in the second month of her first pregnancy
Person with a 30-year, 1 pack per day smoking habit
The nurse is teaching a review class on the lymphatic system. Which statement by a class participant indicates correct understanding of the material? (pg.257)
“Lymph flow is propelled by the contraction of the heart.”
“The flow of lymph is slow, compared with that of the blood.”
“One of the functions of the lymph is to absorb lipids from the biliary tract.”
“Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.”
When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? (pg.257)
Assess the patient’s abdomen, and notice any tenderness.
Carefully assess the cervical lymph nodes, and check for any enlargement.
Ask additional health history questions regarding any recent ear infections or sore throats
Examine the patient’s lower arm and hand, and check for the presence of infection or lesions.
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? (pg.258)
Hard and fixed cervical nodes
Enlarged and tender inguinal nodes
Bilateral enlargement of the popliteal nodes
Pelletlike nodes in the supraclavicular region
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? (pg.258)
Palpable superficial lymph nodes
Excessive swelling of the lymph nodes
No palpable nodes because of the immature immune system of a child
Fewer and smaller sized lymph nodes compared with those of an adult
During an assessment of an older adult, the nurse should expect to which finding as a normal physiologic change associated with the aging process? (pg.258)
Hormonal changes causing vasodilation and a resulting drop in blood pressure
Progressive atrophy of the intramuscular calf veins, causing venous insufficiency
Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for “a couple of minutes”; then he is able to resume his activities. What do these symptoms suggest? (pg.259)
Claudication
Sore muscles
Muscle cramps
Venous insufficiency
A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed “a sore” on the outer aspect of the right ankle. What do these findings suggest? (pg.259)
Pain r/t lymphatic abnormalities
Problems r/t venous insufficiency
Problems r/t arterial insufficiency
Pain r/t musculoskeletal abnormalities
The nurse uses the profile sign during an assessment. What does this technique detect? (pg.260)
Barrel chest
Early clubbing
Symmetry of the fingers
Insufficient capillary refill
The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? (pg.260)
Ask the patient about a history of frostbite.
Suspect that the patient has venous insufficiency.
Consider this a delayed capillary refill time, and investigate further.
Consider this a normal capillary refill time that requires no further assessment.
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient’s skin is warm and capillary refill time is normal. What should the nurse do next? (pg.260)
Check for the presence of claudication.
Refer the individual for further evaluation.
Consider this finding normal, and proceed with the peripheral vascular evaluation.
Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. When assessing this patient’s pulse, what should the nurse expect? (pg.260)
Normal
Bounding
Weak, thready
Non Palpable pedal pulse
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? (pg.261)
To measure the rate of lymphatic drainage
To evaluate the adequacy of capillary patency before venous blood draws
To evaluate the adequacy of collateral circulation before cannulating the radial artery
To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? (pg.261)
Unilateral cool foot
Thin, shiny, atrophic skin
Pallor of the toes and cyanosis of the nail beds
Brownish discoloration to the skin of the lower leg
The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? (pg.261)
Ask the patient to assume a prone position.
Ask the patient to bend his or her knees to the side in a froglike position.
The nurse firmly presses against the bone with the patient in a semi-Fowler position.
The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
When auscultating over a patient’s femoral arteries, the nurse notices the presence of a bruit on the left side. Which statement about bruits is accurate? (pg.262)
Often associated with venous disease
Occur in the presence of lymphadenopathy
Femoral artery bruits are caused by hypermetabolic states
Occur with turbulent blood flow, indicating partial occlusion
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? (pg.262)
1+/0-4+
3+/0-4+
4+/0-4+
Brawny edema
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. When interpreting these findings, what should the nurse recall? (pg.262)
Alterations in arterial function will cause edema.
Nonpitting, hard edema occurs with lymphatic obstruction.
Phlebitis of a superficial vein will cause bilateral edema.
Long-standing arterial obstruction will cause pitting edema.
When assessing a patient’s pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. What do these findings indicate? (pg.263)
Pulsus alternans
Pulsus bisferiens
Pulsus bigeminus
Pulsus paradoxus
During an assessment, the nurse elevated a patient’s legs 12 inches off the table and had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, what should the nurse expect for a normal finding? (pg.263)
Significant elevational pallor
Venous filling within 15 seconds
No change in the coloration of the skin
Color returning to the feet within 20 seconds of assuming a sitting position
During a visit to the clinic, a woman in her seventh month of pregnancy states that her legs feel “heavy in the calf” and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? (pg.263)
Lymphedema
Varicose veins
Raynaud phenomenon
Deep vein thrombophlebitis
During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. Based on these findings, what does the nurse suspect? (pg.264)
Lymphedema
V enous stasis
Arteriosclerosis
Deep-vein thrombosis
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? (pg.264)
Normal ABI indices are from 0.5 to 1.0.
Normal ankle pressure is slightly lower than the brachial pressure.
The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes.
An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.
The nurse is performing a well-child checkup on a 5-year-old boy. The child has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient? (pg.265)
Enlarged, warm, and tender nodes
Lymphadenopathy of the cervical nodes
Palpable firm, small, shotty, mobile, and nontender lymph nodes
Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? (pg.265)
Low humming sound
Swishing, whooshing sound
Regular “lub, dub” pattern
Steady, even, flowing sound
The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? (pg.265)
“Easily palpable; pounds under the fingertips.”
“Greater than normal force that suddenly collapses.”
“Hard to palpate, may fade in and out, and is easily obliterated by pressure.”
“Rhythm is regular, but force varies with alternating beats of large and small amplitude.”
During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. What does the nurse suspect? (pg.266)
Lymphedema
Raynaud phenomenon
Deep-vein thrombosis
Chronic arterial insufficiency
During a routine office visit, a patient takes off his shoes and shows the nurse “this awful sore that won’t heal.” On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. Based on these findings, what does the nurse suspect? (pg.266)
Varicosities
Venous stasis ulcer
Arterial ischemic ulcer
Deep vein thrombophlebitis
The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what type of pulse? (pg.267)
Weak
Absent
Normal
Bounding
A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient’s lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? (Select all that apply.) (pg.267)
Sudden onset
Warm, red, and swollen calf
Pain that is worse at the end of the day
Aching, tired pain, with a feeling of fullness
Intense, sharp pain, with the deep muscle tender to the touch
A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? (Select all that apply.) (pg.267)
Skin of the patient is pale and cool.
His ankles have two small, weeping ulcers.
He states that the pain gets worse when walking.
Patient has a history of diabetes and cigarette smoking.
Patient states that the pain is worse at the end of the day.
