Exam 1 - Peripheral

Question 1

Aneurysm

Answer 1

localized, blood-filled balloon-like bulge in the wall of a blood vessel

Question 2

Ischemia

Answer 2

restriction in blood supply to tissues

Question 3

Profile sign

Answer 3

physical exam of the arms to look at nails from side to detect early clubbing

Question 4

Clubbing

Answer 4

condition affecting the fingers and toes which are abnormally curved

Question 5

Arteriosclerosis

Answer 5

thickening, hardening loss of elasticity of the walls of the arteries

Question 6

Athersclerosis

Answer 6

hardening and narrowing of the arteries, putting blood flow at risk

Question 7

Main Arm Arteries for Pulse Checks

Answer 7

Brachial

Radial

Question 8

Main Leg Arteries for Pulse Checks

Answer 8

Femoral
Popliteal
Dorsalis Pedis
Post Tibial

Question 9

Palpation of pulses

Answer 9

gently apply pressure over the artery
use the pads of first 2-3 fingers
may need to press more firmly on pedal pulses
will need to press more firmly on obese pts/pulses more difficult to palpate

Question 10

3 mechanisms that facilitate blood return to the heart

Answer 10

low pressure gradient
muscular contraction
unidirectional valves

Question 11

What is Arterial Insufficiency?

Answer 11

results from ischemia or inadequate blood supply

Question 12

Risk factors of arterial insufficiency

Answer 12

increasing age, atherosclerosis, hypertension, smoking, male gender, obesity

Question 13

Subjective complaints of arterial insufficiency

Answer 13

recurrent leg pain, cramping, and decreased sensation, worse with walking (claudication) or when legs are elevated, improves with rest or dangling legs

Question 14

Objective findings of arterial insufficiency

Answer 14

pale, cool, shiny, thick textured skin, sluggish capillary refill, decreased hair, thickened toenails, presence of painful non-bleeding arterial ulcer

Question 15

Tests for arterial insufficiency

Answer 15

Trendelenbergs, Allens Test

Question 16

Arterial Ulcers

Answer 16

pale ischemic base, painful, well definded edges with punched out appearance, no drainage, associated with diabetes, neuropathy, infection

Question 17

Risk factors of venous insufficiency

Answer 17

increasing age, history of leg DVT, varicosities or thrombolphelbitis, sitting or standing for long periods of time, bedrest, genetic history, female, obesity

Question 18

Subjective complaints of venous insufficiency

Answer 18

dull aching, heaviness, leg cramping, itching and tingling, pain worse with standing, pain gets better when legs are raised, leg swelling

Question 19

Objective findings of venous insufficiency

Answer 19

edema, superficial varicose veins, thickening and hardening of skin on legs and ankles, texture is thickened.

Question 20

Treatment for venous insufficiency

Answer 20

compression stocking, walking, elevate legs, care for wounds

Question 21

Venous stasis ulcer

Answer 21

shallow, superficial irregular shape, aching pain worse with prolonged sitting or standing at the end of the day

Question 22

Deep Vein Thrombosis

Answer 22

thrombus or clot in the arm or leg, increased risk with bedrest, and for women who take BCP

Question 23

Signs and symptoms of DVT

Answer 23

unilateral pain, swelling, redness and warmth, chest pain, sob, hypoxia, cyanosis, and death

Question 24

Tests for DVT

Answer 24

Homan’s test, flex the foot and note pain in calf, positive if calf pain on dorsiflexion, do not perform Homan’s test with confirmed DVT

Question 25

Function of Lymph Nodes

Answer 25

to fight pathogens

Question 26

What is the purpose of Modified Allen Test?

Answer 26

to examine the superficial and deep palmar arches. Abnormal arches could mean there is acute vascular disease.

Question 27

Grading Edema and Pitting

Answer 27

2mm is 1+ - minimal or no indentation 4mm is 2+ - slight indentation, subsides quickly 6mm is 3+ - moderate adema and indentation 8mm is 4+ - very edematous, pitting indentation lasts a long time

Question 28

Blood Pressure Guidelines

Answer 28

Normal - 120/80 Prehypertension - 120-139, 80-89 Stage 1 Hypertension 140-159, 90-99 Stage 2 Hypertension 160, 100

Question 29

Raynaud's Disease

Answer 29

condition in which the arterioles in the fingers develop spasms, causing intermittent skin palor or cyanosis and then rubor(red color).

Question 30

SS of Raynaud's Disease

Answer 30

spasms last minutes to hours, bilaterally. Numbness or pain during the pallor or cyanotic state and burning and pain during the rubor.

Question 31

Assessment of Leg Ulcers

Answer 31

if skin lesions or ulcers are present, the size and location should be noted. If blackened tissue is discovered, the client must be referred to a Dr. immediately.

Question 32

Assessing Adema

Answer 32

Press the skin for 5 seconds over the tibia, behind the medial malleolus and over the dorsum of each foot. Look for a depression in the skin, caused by pressure of your fingers. If edema is present, grade it.

Question 33

Carotid artery assessment

Answer 33

Client in supine position, place the pads of your first two fingers on the clients neck between the trachea and the sternocleidomastoid muscle below the angle of the jaw. Client to turn head slightly toward your hand to relax the muscle.

Question 34

Carotid Bruit and Thrills

Answer 34

a swishing sound indicates a bruit, increased cardiac output seen in hyperthyroidism or anemia will produce a bruit.

Question 35

Femoral pulse related findings

Answer 35

if it is not palpable, an artery may be occluded

Question 36

Popliteal pulse related findings

Answer 36

if it is not palpable, an artery may be occluded

Question 37

Dorsal pedis pulse findings

Answer 37

absence may not be indicative of an occlusion, because another artery may be supplying blood the area of the foot.

Question 38

Tibial pulse related findings

Answer 38

if it is not palpable, an artery may be occluded, if client has edematous ankles, this pulse may be difficult to palpate

Question 39

If a pulse can't be palpated what is the nurse's next action>

Answer 39

Use the Doppler test

Question 40

The nurse is conducting inspection of the lower extremities for peripheral vascular assessment. Name 3 categories that should be assessed.

Answer 40

Ulcers/varicose veins Adema Color and temperature

Question 41

Name two abnormal findings of arterial insufficiency

Answer 41

sluggish capillary refill, no adema, cool to the touch

Question 42

Name 2 objective findings consistent with DVT

Answer 42

unilateral adema, redness, swelling, warm to the touch