Chapter 51: Assessment of the Vascular System Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 51: Assessment of the Vascular System

MULTIPLE CHOICE

1. When a female client tells the nurse, I always get pains in my legs when walking, the nurse would question her about

a.

amount of activity required to cause pain.

b.

history of hypertension.

c.

number of pregnancies.

d.

presence of swelling.

ANS: A

The extent of the disease can be gauged by the distance the client is able to walk without pain, or the claudication distance.

DIF: Application/Applying REF: pp. 1279-1280

OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. For a client admitted to the hospital with chronic venous disease, the nurses assessment of the clients legs would most likely reveal

a.

decreased pulses.

b.

erythema.

c.

overgrowth of hair.

d.

reduced muscle mass.

ANS: B

Initial skin changes noted with chronic venous disorders may include erythema (redness), followed in later stages by lipodermatosclerosis (brawny, thick, darkly pigmented skin). Decreased pulses would indicate an arterial disorder. Overgrowth of hair is not related. Reduced muscle mass (atrophy) has many causes.

DIF: Application REF: p. 1280 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. A client with venous disease is scheduled for impedance plethysmography. Before the study the nurse would explain that

a.

an intravenous dye may be used.

b.

the procedure is uncomfortable.

c.

venous blood flow quality will be measured.

d.

walking on a treadmill is required.

ANS: C

Impedance plethysmography is used to measure venous blood volume changes in the extremities. Electrodes and a pressure cuff are attached to an extremity. As the pressure cuff is inflated and electrical resistance increases, the quality of venous blood flow can be demonstrated. This non-invasive test does not use dye, does not require walking on a treadmill, nor is it uncomfortable.

DIF: Comprehension/Understanding REF: p. 1288 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

4. To determine if a client with complaints of pain after walking 5 blocks is experiencing intermittent claudication, the nurse would ask

a.

Do you experience leg swelling?

b.

Does pain go away when you rest?

c.

Is the pain cramp-like?

d.

Is the pain in the calf muscle?

ANS: B

Initially the pain of claudication is consistent and develops after a fixed amount of activity (e.g., walking around the block) and disappears within 1-2 minutes of resting.

DIF: Application/Applying REF: p. 1280 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

5. When assessing a client with arterial insufficiency, the nurse would expect

a.

bounding arterial pulses.

b.

cool, pale skin.

c.

muscular atrophy.

d.

warm, erythematous legs.

ANS: B

Hallmarks of arterial insufficiency include decreased or absent pulses; possible systolic bruit over involved arteries; muscular atrophy; thin, shiny, hairless skin; thick, ridged toenails; cool skin temperature; and ulcers on pressure points of feet.

DIF: Comprehension/Understanding REF: p. 1286 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

6. During lower extremity inspection of a client with early chronic venous disease, the nurse would expect to find

a.

decreased peripheral pulses.

b.

dependent cyanosis.

c.

muscular hypertrophy.

d.

pitting edema of the lower extremities.

ANS: D

In more severe forms of chronic venous disorders, lower extremity edema is the usual initial complaint. Pitting edema may be seen at first, but as the edema becomes more chronic, scarring develops and the pitting disappears.

DIF: Comprehension/Understanding REF: p. 1280 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

7. The nurse tests the capillary refill on a clients lower extremity and notes that it takes 4 seconds for the color to return to baseline. It would be most important for the nurse to then check for

a.

constricting clothing.

b.

other indicators of peripheral perfusion.

c.

presence of venous ulcers.

d.

prior surgery on this extremity.

ANS: B

Capillary refill time is an evaluation of peripheral perfusion and cardiac output. Normal is up to 3 seconds; 4 seconds is too slow, so the nurse should do further assessments of peripheral perfusion. Certainly constrictive clothing might be a problem, but that would be considered as part of the peripheral perfusion assessment. Venous ulceration is also part of an assessment of peripheral perfusion. Prior surgery may or may not be related.

DIF: Application/Applying REF: p. 1285 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Techniques of Physical Assessment

8. A client is taking garlic and hawthorn supplements. The nurse would ask further questions to elicit information on a possible history of

a.

atherosclerosis.

b.

hypertension.

c.

smoking.

d.

varicose veins.

ANS: B

Herbal preparations that are used to self-treat hypertension include garlic, hawthorn, kudzu, nettle, onion, purslane, reishi mushrooms, and valerian.

DIF: Application/Applying REF: p. 1282 OBJ: Assessment

MSC: Physiological Integrity Basic Care and Comfort-Complementary and Alternative Therapies

9. A client has a 30 mm Hg difference in blood pressures in the arms. For subsequent blood pressure readings, the nurse should use

a.

a larger blood pressure cuff.

b.

a smaller blood pressure cuff.

c.

the arm with the higher reading.

d.

the arm with the lower reading.

ANS: C

difference in blood pressure of 20 mm Hg or more may indicate other medical problems. This discrepancy should be documented. The nurse should use the arm with the higher reading for all subsequent blood pressure measurements.

DIF: Application/Applying REF: p. 1287 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Techniques of Physical Assessment

10. A client has a suspected DVT. The nurse would prepare the client to undergo a

a.

air plethysmography.

b.

ankle-brachial index measurement.

c.

computed tomography (CT) scan.

d.

ultrasonic duplex scan.

ANS: D

The ultrasonic duplex scanner is used to localize vascular obstruction, evaluate the degree of stenosis, and determine the presence or absence of vascular reflux. It is also the most sensitive and specific non-invasive test for detecting DVT.

DIF: Application/Applying REF: pp. 1287-1288

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

MULTIPLE RESPONSE

1. During a physical exam, the nurse asks the client about medical problems that can impact vascular health, including (Select all that apply)

a.

diabetes.

b.

heart disease.

c.

stroke or TIA.

d.

gallbladder disease.

e.

prior frostbite.

ANS: A, B, C, E

The nurse should specifically question the client about hypertension, diabetes, stroke, TIAs, changes in vision, phlebitis, history of blood clots, pulmonary emboli, varicose veins, or a previous history of frostbite.

DIF: Comprehension/Understanding REF: p. 1280 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Screening

2. Age-related changes the nurse incorporates into interpreting the physical assessment for vascular disorders include (Select all that apply)

a.

blood pressure readings are often inaccurate in older people.

b.

dorsalis pedis and posterior tibial pulses may be more difficult to palpate.

c.

peripheral vascular disease is common among the elderly.

d.

skin changes, such as dependent rubor, are often seen in people over 65.

ANS: B, C

Atherosclerosis and peripheral vascular disease are both more common in the elderly population. Also, the dorsalis pedis and posterior tibial pulses may be more difficult to palpate. Blood pressure readings should not be inaccurate in older people, and dependent rubor is not seen in older clients in the absence of venous disorders.

DIF: Application/Applying REF: pp. 1279, 1287

OBJ: Assessment

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Changes

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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