Chapter 37: Vascular Disorders Nursing School Test Banks

Chapter 37: Vascular Disorders
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. What is a normal age-related change in older adults that makes them susceptible to cardiovascular disease?
a. Increase in cardiac output
b. Increase in stroke volume
c. Stiff peripheral vessels
d. Oxygen capacity improvement
ANS: C
As adults age, their peripheral vessels become stiff, their oxygen capacity and stroke volume are reduced, and their aorta thickens and calcifies.

DIF: Cognitive Level: Knowledge REF: p. 740 OBJ: 1
TOP: Changes in Older Adults KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. What should a nurse ask a patient related to past history of deep-vein thrombosis (DVT) and other vascular problems?
a. An aneurysm
b. Rheumatoid arthritis
c. A peptic ulcer
d. Recurring chest pain
ANS: D
Pain in the chest or dyspnea suggests that a pulmonary embolism may have occurred from the presence of a DVT. Approximately 10% of individuals with DVT develop pulmonary emboli.

DIF: Cognitive Level: Application REF: p. 741 OBJ: 4
TOP: Venous Disorders KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. A 69-year-old patient reports a burning, aching pain in the legs when walking to the mailbox. These symptoms are relieved with rest. What should the nurse suspect?
a. Venous insufficiency
b. Claudication
c. Phlebitis
d. Rest pain
ANS: B
Arterial vascular disorders that produce pain with activity are defined as claudication, which is the result of ischemia of the tissues caused by a lack of adequate perfusion.

DIF: Cognitive Level: Application REF: p. 741 OBJ: 4
TOP: Claudication KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. A nurse records the assessment of stasis dermatitis on an intake assessment for a patient with peripheral vascular disease (PVD). What is the best way to describe this finding?
a. Brownish skin discoloration on the lower legs
b. Ulceration on medial surface of the lower legs
c. Edema in the lower legs
d. Purple rash on medial surface of the lower legs
ANS: A
Stasis dermatitis is a brownish skin discoloration on the lower legs, which is indicative of venous stasis.

DIF: Cognitive Level: Application REF: p. 742 OBJ: 2
TOP: Vascular Disorders KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. A nurse assesses a patients capillary refill time as less than 3 seconds. What does this assessment indicate?
a. Hypertension
b. Tissue perfusion
c. Excess fluid volume
d. Increased blood viscosity
ANS: B
Capillary refill is determined by compressing the nail bed until it blanches. With a normal capillary refill, color returns to the blanched skin within 3 seconds.

DIF: Cognitive Level: Comprehension REF: p. 742 OBJ: 2
TOP: Capillary Refill KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. A nurse performs Homans maneuver by flexing the knee and sharply dorsiflexing the foot. What response indicates a positive Homans sign?
a. Cramping of the toes
b. Resisting dorsiflexion
c. Pain in the calf area
d. Blanching of the sole
ANS: C
A positive Homans sign indicates the possible presence of a DTV because of the pain produced in the calf of the leg when the foot is dorsiflexed.

DIF: Cognitive Level: Comprehension REF: p. 742 OBJ: 2
TOP: Homans Sign KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. Which technique should the nurse implement when performing the Allen test on a patient to evaluate the adequacy of circulation in the radial artery?
a. Asks the patient to relax the hand by the side
b. Compresses only the ulnar artery to blanch the hand
c. Releases pressure on both arteries at the same time
d. Observes whether the color is returning to the hand, which indicates perfusion
ANS: D
The Allen test is performed to evaluate circulation in the hand, both in the radial and the ulnar arteries. The patient is asked to make a fist. The nurse compresses both the ulnar and the radial artery to blanch the hand. The patient is asked to open the hand as the nurse releases pressure on one or the other of the arteries. Color returning to the hand confirms perfusion.

DIF: Cognitive Level: Application REF: p. 742 OBJ: 2
TOP: Allen Test KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. A nurse records that a patient has a 3+ edema to the right foot. How deep did the nurses thumb depress the edematous area?
a. More than 1 inch
b. To 1 inch
c. To inch
d. Less than inch
ANS: B
Edema is measured by the depth of the depression of the thumb: 1 = less than inch, 2 = to inch, 3 = to 1 inch, and 4 = more than 1 inch.

DIF: Cognitive Level: Comprehension REF: p. 742 OBJ: 2
TOP: Assessing for Edema KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. A nurse notes ulcerations on the surfaces of a patients toes. What should this assessment most likely indicate?
a. Skin breakdown from pressure
b. Nutritional deficit
c. Venous stasis
d. Arterial stasis
ANS: D
Arterial stasis ulcers on the tips of the patients toes are indicators of arterial insufficiency. This is a serious and probably progressive disorder that leads to further risk of impaired skin integrity.

DIF: Cognitive Level: Application REF: p. 742 OBJ: 2
TOP: Arterial Toe Ulcers KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. What is a characteristic of a venous stasis ulcer?
a. Painlessness
b. Poikilothermy
c. Pale color
d. Location near the groin
ANS: A
Venous ulcers are painless ulcers near the ankle that are warm and have a ruddy color.

DIF: Cognitive Level: Knowledge REF: p. 742 OBJ: 3
TOP: Venous Stasis Ulcer KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. A nurse is caring for a patient who has had an angiogram. What should the nurse make a point of care to assess and document on this patient?
a. Fluid intake
b. Peripheral pulses in the affected leg
c. Inquiring about an allergy to iodine
d. Decreased blood pressure
ANS: B
Checking and recording the presence and strength of the pulses in the affected leg ensure that the injection site has not occluded the vessel and that vascular spasm has not impaired circulation. An inquiry about an iodine allergy is made before the procedure.

DIF: Cognitive Level: Application REF: p. 744-745 OBJ: 3
TOP: Postangiogram Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. A nurse is educating a patient regarding a stress test on a treadmill. Teaching includes that this test is a noninvasive procedure. What additional information is appropriate for the nurse to include?
a. Is monitored continuously by blood pressure and an electrocardiogram
b. Will last about 1 hour
c. Is meant to stimulate claudication and dyspnea
d. Will require a period of bedrest afterward
ANS: A
The examination requires the patient to walk at a rate of approximately 1.5 miles per hour. The exercise is continually monitored and is terminated if the patient experiences pain or dyspnea.

DIF: Cognitive Level: Comprehension REF: p. 744-745 OBJ: 3
TOP: Treadmill Stress Test KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

13. A patient inquires how something as simple as walking could help his venous vascular disorder. What is the best response by the nurse when explaining the benefits of walking?
a. Improves the strength of the vascular walls
b. Boosts venous circulation through leg muscle activity
c. Increases cardiac output
d. Clears plaques from the veins
ANS: B
Walking is helpful because the muscle action of the legs that massage the valves of the veins boosts circulation.

DIF: Cognitive Level: Comprehension REF: p. 745 OBJ: 5
TOP: Benefits of Walking KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

14. What is contraindicated for a patient performing Buerger-Allen exercises?
a. Lying on the stomach
b. Raising legs for 2 minutes until they blanch
c. Lowering the legs until the color returns
d. Keeping legs flat for 5 minutes and then repeat the exercise
ANS: A
Buerger-Allen exercises promote emptying of the blood vessels by gravity. Initially, lying on the back and elevating the legs will result in pallor, and then lowering the legs will allow color to return.

DIF: Cognitive Level: Comprehension REF: p. 745-746 OBJ: 5
TOP: Buerger-Allen Exercises KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

15. A nurse cautions a patient with peripheral vascular disease (PVD) that continued smoking causes detrimental vasoconstriction for up to ____ after only one cigarette.
a. 10 minutes
b. 20 minutes
c. 30 minutes
d. 1 hour
ANS: D
Smoking restricts circulation by vasoconstriction and lasts up to 1 hour after a cigarette; it also causes vasospasm.

DIF: Cognitive Level: Knowledge REF: p. 746 OBJ: 5
TOP: Smoking Cessation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

16. A nurse is performing an intake examination on a patient with peripheral vascular disease (PVD). Which lifestyle information identified by the patient aggravates vascular disease?
a. Riding a bicycle to work
b. Drinking red wine every day
c. Being employed as an air traffic controller
d. Eating chocolate candy every day
ANS: C
Employment as an air controller is a stressful occupation. Stress increases vasoconstriction and increases vascular resistance. Wine and chocolate actually have beneficial effects on circulation, as does bicycle riding.

DIF: Cognitive Level: Application REF: p. 746-747 OBJ: 5
TOP: Stress and PVD KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

17. Vascular disease disorders often require the use of elastic stockings. Which action should the nurse implement when caring for a patient with elastic stockings?
a. Apply the stockings and roll down the cuff.
b. Remove the stockings for skin inspection two times a day.
c. Remove the stockings when the patient is ambulating.
d. Inspect the skin for pressure or irritation daily.
ANS: B
Elastic stockings improve blood flow. They should be applied early in the morning. They should be removed twice daily for 20 to 30 minutes, and the skin integrity of the feet should be examined.

DIF: Cognitive Level: Application REF: p. 746 OBJ: 5
TOP: Vascular Disease and Elastic Stockings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

18. Which instruction is most appropriate for a patient with arterial insufficiency?
a. Frequently allow the legs to dangle dependently.
b. Rub the legs vigorously.
c. Stand often to keep blood flow in the legs.
d. Walk barefoot.
ANS: A
Dangling legs can use gravity to help with arterial circulation. Vigorous rubbing of the legs is contraindicated, and prolonged standing strains the vascular system. The patient should never walk barefoot.

DIF: Cognitive Level: Comprehension REF: p. 745-746 OBJ: 4
TOP: Home Instruction for the Patient with a Vascular Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. A nurse is preparing to administer low-molecular-weight heparin (LMWH). What is a major advantage related to the administration of LMWH?
a. It can be given orally.
b. It is provided fixed doses.
c. It is given only after partial thromboplastin time (PTT) laboratory work.
d. It provides an immediate effect.
ANS: B
LMWH can be given as a fixed dose without waiting for the results of the PTT. It is only given subcutaneously and does not have an immediate effect. PTT is not done to monitor LMWH.

DIF: Cognitive Level: Comprehension REF: p. 751 OBJ: 4
TOP: Anticoagulant Drug Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

20. Which statement made by a patient indicates to the nurse that a teaching plan for the use of warfarin was not effective?
a. I dont take aspirin anymore.
b. I read that grapefruit interferes with warfarin.
c. Im drinking too much tea. My urine looks like tea.
d. I wear my medical alert bracelet all the time.
ANS: C
Anticoagulants, such as warfarin (Coumadin), can cause bleeding. A sign of bleeding may be bruising, tea- or cola-colored urine, or dark-colored stool.

DIF: Cognitive Level: Application REF: p. 751 OBJ: 5
TOP: Anticoagulant Therapy KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

21. A patient has returned from a vein ligation and stripping. What are the appropriate instructions for a nurse to provide?
a. Dangle the legs to prevent edema.
b. Cross the legs to apply pressure.
c. Wear compression stockings to promote circulation.
d. Remove the drain after 24 hours.
ANS: C
Postoperative care of a patient with a vein ligation and stripping includes elevating the extremity, wearing compression stockings, taking anticoagulant therapy, and assessing the circulation of the affected extremity.

DIF: Cognitive Level: Application REF: p. 761 OBJ: 5
TOP: Vein Ligation and Stripping KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

22. What medication obtained in a patients history will lessen the effects of warfarin (Coumadin)?
a. Iron supplement for anemia
b. Simvastatin (Zocor) for the control of cholesterol
c. Furosemide (Lasix) for fluid retention
d. Yaz (drospirenone/estradiol) as an oral contraceptive
ANS: D
Oral contraceptives lessen the effects of warfarin (Coumadin).

DIF: Cognitive Level: Knowledge REF: p. 751 OBJ: 5
TOP: Drug Therapy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

23. An obese postsurgical patient complains of sudden discomfort in her leg. The nurse assesses the leg and finds it cold and pale with no pedal or popliteal pulse. What should the nurse suspect?
a. Venous thrombosis
b. Arterial occlusion
c. Vascular spasm
d. Paresthesia
ANS: B
Signs of an acute arterial occlusion can include severe pain, absent pulses, or very pale or mottled skin.

DIF: Cognitive Level: Application REF: p. 754 OBJ: 4
TOP: Acute Arterial Occlusion KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

24. Which postoperative sign should a nurse report immediately when caring for a patient with an endarterectomy with a synthetic graft?
a. Headache
b. Fever
c. Edema
d. Pain
ANS: B
A fever in a patient with a synthetic graft is a serious postoperative event. The infection may lead to an amputation.

DIF: Cognitive Level: Comprehension REF: p. 755 OBJ: 4
TOP: Surgical Repair with Synthetic Graft
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

25. A patient with Raynaud disease has a nursing diagnosis of Ineffective tissue perfusion, related to vasoconstriction and is being given discharge instructions. What should the nurse include when providing this information?
a. Avoid sun exposure.
b. Wear gloves and warm socks when outdoors.
c. Chafe hands frequently to warm them.
d. Wash dishes in warm water.
ANS: B
Chafing hands to warm them does not provide vasodilation and may cause tissue damage. Avoiding exposure to cold is paramount to prevent pain and tissue damage. Raynaud disease involves the constriction of the arterioles of the hands, toes, and nose. Pain is a cardinal symptom and can be relieved with methods to promote vasodilation.

DIF: Cognitive Level: Application REF: p. 758 OBJ: 4
TOP: Raynaud Disease KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

26. What assessment should a nurse perform on a patient after the repair of an abdominal aortic aneurysm?
a. Periorbital edema
b. Tremor or facial twitching
c. Rising blood pressure
d. Bowel sounds
ANS: D
Repair of aortic abdominal aneurysms cause a temporary cessation of peristalsis. Although this condition is expected, the beginning of bowel sounds indicates important progress in the recovery. Rising blood pressure is an expected recovery indication from surgery.

DIF: Cognitive Level: Application REF: p. 759-760 OBJ: 4
TOP: Aneurysm of the Abdominal Aorta KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

27. What patient teaching should be included for a patient with varicose veins?
a. Weight reduction
b. Decreasing exercise
c. Wearing a panty girdle
d. Standing rather than sitting
ANS: A
Varicose veins are caused by a dilation of incompetent valves. Obesity, pregnancy, restrictive clothing, and prolonged standing aggravate the condition.

DIF: Cognitive Level: Application REF: p. 760-761 OBJ: 4
TOP: Varicose Veins KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

28. Why do older persons adapt more slowly to changes in the peripheral vascular system? (Select all that apply.)
a. Slowing heart rate
b. Decreasing cardiac output
c. Increasing stroke volume
d. Stiffening of blood vessels
e. Thickening of aorta
ANS: A, B, D, E
Age-related changes include a slowing of the heart rate, a decrease in both cardiac output and stroke volume, and a stiffening and thickening of blood vessels.

DIF: Cognitive Level: Comprehension REF: p. 740 OBJ: 4
TOP: Age-Related Changes to the Cardiovascular System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. A nurse suspects a circulatory disorder in one leg. Which assessments should the nurse include when comparing both legs? (Select all that apply.)
a. Color
b. Warmth
c. Muscle strength
d. Pulse quality
e. Hair loss on extremity
ANS: A, B, D, E
Muscle strength is not a circulatory assessment. Color, warmth, pulse quality, and loss of superficial hair are indicators of decreased arterial perfusion.

DIF: Cognitive Level: Application REF: p. 740-741 OBJ: 2
TOP: Circulatory Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

30. A nurse explains that the lining of a vessel that allows for smooth blood flow and also reduced resistance in the vessel is the _____ of the vessel.

ANS:
intima
The interior lining of a blood vessel is referred to as the intima.

DIF: Cognitive Level: Knowledge REF: p. 737 OBJ: 1
TOP: Intima KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. A nurse explains that when a patient history reveals a recent episode of vomiting and diarrhea, the nurse anticipates that this fluid loss will cause _____ and increased blood viscosity.

ANS:
hemoconcentration
Hemoconcentration occurs when fluid is lost through dehydration, which makes the blood more viscous and shows an inaccurately high value of hemoglobin.

DIF: Cognitive Level: Comprehension REF: p. 740 OBJ: 1
TOP: Hemoconcentration KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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