NR 304 Health Assessment II Exam 1
I I I I I I I
Chapter 21 I
Jarvis: IPhysical IExamination I& IHealth IAssessment, I7th IEdition I1.Which Istatement Iis Itrue
Iregarding I the I arterial I system?
The Iarterial Isystem Iis Ia Ihigh-pressure Isystem.
The Inurse Iis Ireviewing Ithe Iblood Isupply Ito Ithe Iarm. IThe Imajor Iartery Isupplying Ithe Iarm Iis Ithe I_
Iartery.
Brachial
The Inurse Iis Ipreparing Ito Iassess Ithe Idorsalis Ipedis Iartery. IWhere Iis Ithe Icorrect Ilocation Ifor
Ipalpation?
Lateral Ito Ithe Iextensor Itendon Iof Ithe Igreat Itoe
A I65-year-old Ipatient Iis Iexperiencing Ipain Iin Ihis Ileft Icalf Iwhen Ihe Iexercises Ithat Idisappears Iafter
Iresting I for I a I few I minutes. I The I nurse I recognizes I that I this I description I is I most I consistent I with
Ithe I left I leg.
Ischemia Icaused Iby Ia Ipartial Iblockage Iof Ian Iartery Isupplying
The Inurse Iis Ireviewing Ivenous Iblood Iflow Ipatterns. IWhich Iof Ithese Istatements Ibest Idescribes
Ithe Imechanism(s) Iby I which I venous I blood Ireturns Ito Ithe Iheart?
Intraluminal Ivalves Iensure Iunidirectional Iflow Itoward Ithe Iheart
Which Ivein(s) Iis(are) Iresponsible Ifor Imost Iof Ithe Ivenous Ireturn Iin Ithe Iarm?
Superficial
I
A I70-year-old Ipatient Iis Ischeduled Ifor Iopen-heart Isurgery. IThe Isurgeon Iplans Ito Iuse Ithe Igreat
Isaphenous Ivein Ifor Ithe Icoronary Ibypass I grafts. I The Ipatient I asks, I“What Ihappens I to Imy
Icirculation I when Ithis I vein I is I removed?” I The I nurse I should I reply:
“This Ivein Ican Ibe Iremoved Iwithout Iharming Iyour Icirculation Ibecause Ithe Ideeper Iveins Iin Iyour
Ileg I are I in I good I condition.”
The Inurse Iis Ireviewing Ithe Irisk Ifactors Ifor Ivenous Idisease. IWhich Iof Ithese Isituations Ibest
Idescribes Ia Iperson I at I highest Irisk Ifor I the I development Iof I venous I disease?
Person Iwho Ihas Ibeen Ion Ibed Irest Ifor I4 Idays
The Inurse Iis Iteaching Ia Ireview Iclass Ion Ithe Ilymphatic Isystem. IA Iparticipant Ishows Icorrect
Iunderstanding I of Ithe I material I with I which I statement?
“The Iflow Iof Ilymph Iis Islow, Icompared Iwith Ithat Iof Ithe Iblood.”
When Iperforming Ian Iassessment Iof Ia Ipatient, Ithe Inurse Inotices Ithe Ipresence Iof Ian Ienlarged
Iright I epitrochlear I lymph Inode. I What Ishould Ithe I nurse Ido I next?
,Examine Ithe Ipatient’s Ilower Iarm Iand Ihand, Iand Icheck Ifor Ithe Ipresence Iof Iinfection Ior Ilesions.
A I35-year-old Iman Iis Iseen Iin Ithe Iclinic Ifor Ian Iinfection Iin Ihis Ileft Ifoot. IWhich Iof Ithese Ifindings
Ishould Ithe Inurse I expect Ito Isee I during I an I assessment I of Ithis I patient?
Enlarged Iand Itender Iinguinal Inodes
The Inurse Iis Iexamining Ithe Ilymphatic Isystem Iof Ia Ihealthy I3-year-old Ichild. IWhich Ifinding Ishould
Ithe I nurse I expect?
Presence Iof Ipalpable Ilymph Inodes
During Ian Iassessment Iof Ian Iolder Iadult, Ithe Inurse Ishould Iexpect Ito Inotice Iwhich Ifinding Ias Ia
Inormal Iphysiologic I change I associated I with I the Iaging I process?
Peripheral Iblood Ivessels Igrowing Imore Irigid Iwith Iage, Iproducing Ia Irise Iin Isystolic Iblood
Ipressure
A I67-year-old Ipatient Istates Ithat Ihe Irecently Ibegan Ito Ihave Ipain Iin Ihis Ileft Icalf Iwhen Iclimbing Ithe
I10 Istairs Ito Ihis Iapartment. IThis Ipain Iis Irelieved Iby Isitting Ifor Iapproximately I2 Iminutes; Ithen Ihe Iis
Iable Ito Iresume Ihis Iactivities. IThe Inurse Iinterprets Ithat Ithis Ipatient Iis Imost Ilikely Iexperiencing:
Claudication.
A Ipatient Icomplains Iof Ileg Ipain Ithat Iwakes Ihim Iat Inight. IHe Istates Ithat Ihe I“has Ibeen Ihaving
Iproblems” Iwith Ihis Ilegs. IHe Ihas Ipain Iin Ihis Ilegs Iwhen Ithey Iare Ielevated Ithat Idisappears Iwhen
Ihe Idangles Ithem. IHe Irecently Inoticed I“a Isore” Ion Ithe Iinner I aspect Iof Ithe Iright Iankle. IOn Ithe
Ibasis Iof Ithis Ihealth Ihistory Iinformation, Ithe Inurse Iinterprets Ithat Ithe Ipatient Iis Imost Ilikely
Iexperiencing:
Problems Irelated Ito Iarterial Iinsufficiency.
During Ian Iassessment, Ithe Inurse Iuses Ithe Iprofile Isign Ito Idetect:
Early Iclubbing.
The Inurse Iis Iperforming Ian Iassessment Ion Ian Iadult. IThe Iadult’s Ivital Isigns Iare Inormal, Iand
Icapillary Irefill I time I is I 5 I seconds. I What I should I the Inurse I do I next?
Consider Ithis Ia Idelayed Icapillary Irefill Itime, Iand Iinvestigate Ifurther.
When Iassessing Ia Ipatient, Ithe Inurse Inotes Ithat Ithe Ileft Ifemoral Ipulse Ias Idiminished, I1+/4+.
IWhat I should Ithe I nurse I do Inext?
Auscultate Ithe Isite Ifor Ia Ibruit.
When Iperforming Ia Iperipheral Ivascular Iassessment Ion Ia Ipatient, Ithe Inurse Iis Iunable Ito IpalpateIthe
Iulnar Ipulses. IThe Ipatient’s Iskin Iis Iwarm Iand Icapillary Irefill Itime Iis Inormal. INext, Ithe Inurse Ishould:
Consider Ithis Ifinding Ias Inormal, Iand Iproceed Iwith Ithe Iperipheral Ivascular Ievaluation.
,The Inurse Iis Iassessing Ithe Ipulses Iof Ia Ipatient Iwho Ihas Ibeen Iadmitted Ifor Iuntreated
Ihyperthyroidism. IThe Inurse Ishould Iexpect Ito Ifind Ia(n) pulse.
Bounding
The Inurse Iis Ipreparing Ito Iperform Ia Imodified IAllen Itest. IWhich Iis Ian Iappropriate Ireason Ifor Ithis
Itest?
To Ievaluate Ithe Iadequacy Iof Icollateral Icirculation Ibefore Icannulating Ithe Iradial Iartery
A Ipatient Ihas Ibeen Idiagnosed Iwith Ivenous Istasis. IWhich Iof Ithese Ifindings Iwould Ithe
Inurse Imost Ilikely I observe?
Brownish Idiscoloration Ito Ithe Iskin Iof Ithe Ilower Ileg
The Inurse Iis Iattempting Ito Iassess Ithe Ifemoral Ipulse Iin Ia Ipatient Iwho Iis Iobese. IWhich Iof Ithese
Iactions I would I be I most I appropriate?
The Ipatient Iis Iasked Ito Ibend Ihis Ior Iher Iknees Ito Ithe Iside Iin Ia Ifroglike Iposition.
When Iauscultating Iover Ia Ipatient’s Ifemoral Iarteries, Ithe Inurse Inotices Ithe Ipresence Iof Ia Ibruit Ion
Ithe I left I side. I The I nurse I knows I that I bruits:
Occur Iwith Iturbulent Iblood Iflow, Iindicating Ipartial Iocclusion.
How Ishould Ithe Inurse Idocument Imild, Islight Ipitting Iedema Ithe Iankles Iof Ia Ipregnant Ipatient?
1+/0-4+
I
A Ipatient Ihas Ihard, Inonpitting Iedema Iof Ithe Ileft Ilower Ileg Iand Iankle. IThe Iright Ileg Ihas Ino
Iedema. I Based I on I these Ifindings, I the I nurse Irecalls I that:
Nonpitting, Ihard Iedema Ioccurs Iwith Ilymphatic Iobstruction.
When Iassessing Ia Ipatient’s Ipulse, Ithe Inurse Inotes Ithat Ithe Iamplitude Iis Iweaker Iduring
Iinspiration Iand Istronger Iduring Iexpiration. IWhen Ithe Inurse Imeasures Ithe Iblood Ipressure, Ithe
Ireading Idecreases I20 Imm IHg Iduring Iinspiration Iand Iincreases Iwith Iexpiration. IThis Ipatient Iis
Iexperiencing I pulsus:
Paradoxus.
During Ian Iassessment, Ithe Inurse Ihas Ielevated Ia Ipatient’s Ilegs I12 Iinches Ioff Ithe Itable Iand Ihas
Ihad Ihim Iwag Ihis Ifeet Ito Idrain Ioff Ivenous Iblood. IAfter Ihelping Ihim Isit Iup Iand Idangle Ihis Ilegs Iover
Ithe Iside Iof Ithe Itable, I the Inurse Ishould I expect Ithat Ia Inormal Ifinding I at I this Ipoint I would Ibe:
Venous Ifilling Iwithin I15 Iseconds.
, During Ia Ivisit Ito Ithe Iclinic, Ia Iwoman Iin Iher Iseventh Imonth Iof Ipregnancy Icomplains Ithat Iher Ilegs
Ifeel I“heavy Iin Ithe Icalf” Iand Ithat Ishe Ioften Ihas Ifoot Icramps Iat I night. IThe Inurse Inotices Ithat Ithe
Ipatient Ihas Idilated, Itortuous Iveins Iapparent Iin Iher Ilower Ilegs. IWhich Icondition Iis Ireflected Iby
Ithese Ifindings?
Varicose Iveins
During Ian Iassessment, Ithe Inurse Inotices Ithat Ia Ipatient’s Ileft Iarm Iis Iswollen Ifrom Ithe Ishoulder
Idown Ito Ithe Ifingers, Iwith Inonpitting Ibrawny Iedema. IThe Iright Iarm Iis Inormal. IThe Ipatient Ihad Ia
Ileft-sided I mastectomy I 1 Iyear I ago. I The I nurse I suspects Iwhich I problem?
Lymphedema
The Inurse Iis Ipreparing Ito Iassess Ithe Iankle-brachial Iindex I(ABI) Iof Ia Ipatient. IWhich Istatement
Iabout I the I ABI I is I true?
An IABI Iof I0.9 Ito I0.7 Iindicates Ithe Ipresence Iof Iperipheral Ivascular Idisease Iand Imild Iclaudication.
The Inurse Iis Iperforming Ia Iwell-child Icheckup Ion Ia I5-year-old Iboy. IHe Ihas Ino Icurrent Icondition
Ithat Iwould Ilead Ithe Inurse Ito Isuspect I an Iillness. IHis Ihealth Ihistory Iis Iunremarkable, I and Ihe
Ireceived Iimmunizations I1 Iweek Iago. IWhich Iof Ithese Ifindings Ishould Ibe Iconsidered Inormal Iin
Ithis Ipatient?
Palpable Ifirm, Ismall, Ishotty, Imobile, Iand Inontender Ilymph Inodes
When Iusing Ia IDoppler Iultrasonic Istethoscope, Ithe Inurse Irecognizes Ivenous Iflow Iwhen Iwhich
Isound I is I heard?
Swishing, Iwhooshing Isound
The Inurse Iis Idescribing Ia Iweak, Ithready Ipulse Ion Ithe Idocumentation Iflow Isheet. IWhich
Istatement I is I correct?
“Is Ihard Ito Ipalpate, Imay Ifade Iin Iand Iout, Iand Iis Ieasily Iobliterated Iby Ipressure.”
During Ian Iassessment, Ia Ipatient Itells Ithe Inurse Ithat Iher Ifingers Ioften Ichange Icolor Iwhen
Ishe Igoes Iout Iin I cold Iweather. IShe Idescribes Ithese Iepisodes Ias Iher Ifingers Ifirst Iturning
Iwhite, Ithen Iblue, Ithen I red Iwith Ia Iburning, Ithrobbing Ipain. IThe Inurse Isuspects Ithat Ishe Iis
Iexperiencing:
Raynaud Idisease.
During Ia Iroutine Ioffice Ivisit, Ia Ipatient Itakes Ioff Ihis Ishoes Iand Ishows Ithe Inurse I“this Iawful Isore
Ithat Iwon’t Iheal.” IOn Iinspection, Ithe Inurse Inotes Ia I3-cm Iround Iulcer Ion Ithe Ileft Igreat Itoe, Iwith Ia
Ipale Iischemic Ibase, Iwell-defined Iedges, Iand Ino Idrainage. IThe Inurse Ishould Iassess Ifor Iother
Isigns I and I symptoms I of:
Arterial Iischemic Iulcer.
I I I I I I I
Chapter 21 I
Jarvis: IPhysical IExamination I& IHealth IAssessment, I7th IEdition I1.Which Istatement Iis Itrue
Iregarding I the I arterial I system?
The Iarterial Isystem Iis Ia Ihigh-pressure Isystem.
The Inurse Iis Ireviewing Ithe Iblood Isupply Ito Ithe Iarm. IThe Imajor Iartery Isupplying Ithe Iarm Iis Ithe I_
Iartery.
Brachial
The Inurse Iis Ipreparing Ito Iassess Ithe Idorsalis Ipedis Iartery. IWhere Iis Ithe Icorrect Ilocation Ifor
Ipalpation?
Lateral Ito Ithe Iextensor Itendon Iof Ithe Igreat Itoe
A I65-year-old Ipatient Iis Iexperiencing Ipain Iin Ihis Ileft Icalf Iwhen Ihe Iexercises Ithat Idisappears Iafter
Iresting I for I a I few I minutes. I The I nurse I recognizes I that I this I description I is I most I consistent I with
Ithe I left I leg.
Ischemia Icaused Iby Ia Ipartial Iblockage Iof Ian Iartery Isupplying
The Inurse Iis Ireviewing Ivenous Iblood Iflow Ipatterns. IWhich Iof Ithese Istatements Ibest Idescribes
Ithe Imechanism(s) Iby I which I venous I blood Ireturns Ito Ithe Iheart?
Intraluminal Ivalves Iensure Iunidirectional Iflow Itoward Ithe Iheart
Which Ivein(s) Iis(are) Iresponsible Ifor Imost Iof Ithe Ivenous Ireturn Iin Ithe Iarm?
Superficial
I
A I70-year-old Ipatient Iis Ischeduled Ifor Iopen-heart Isurgery. IThe Isurgeon Iplans Ito Iuse Ithe Igreat
Isaphenous Ivein Ifor Ithe Icoronary Ibypass I grafts. I The Ipatient I asks, I“What Ihappens I to Imy
Icirculation I when Ithis I vein I is I removed?” I The I nurse I should I reply:
“This Ivein Ican Ibe Iremoved Iwithout Iharming Iyour Icirculation Ibecause Ithe Ideeper Iveins Iin Iyour
Ileg I are I in I good I condition.”
The Inurse Iis Ireviewing Ithe Irisk Ifactors Ifor Ivenous Idisease. IWhich Iof Ithese Isituations Ibest
Idescribes Ia Iperson I at I highest Irisk Ifor I the I development Iof I venous I disease?
Person Iwho Ihas Ibeen Ion Ibed Irest Ifor I4 Idays
The Inurse Iis Iteaching Ia Ireview Iclass Ion Ithe Ilymphatic Isystem. IA Iparticipant Ishows Icorrect
Iunderstanding I of Ithe I material I with I which I statement?
“The Iflow Iof Ilymph Iis Islow, Icompared Iwith Ithat Iof Ithe Iblood.”
When Iperforming Ian Iassessment Iof Ia Ipatient, Ithe Inurse Inotices Ithe Ipresence Iof Ian Ienlarged
Iright I epitrochlear I lymph Inode. I What Ishould Ithe I nurse Ido I next?
,Examine Ithe Ipatient’s Ilower Iarm Iand Ihand, Iand Icheck Ifor Ithe Ipresence Iof Iinfection Ior Ilesions.
A I35-year-old Iman Iis Iseen Iin Ithe Iclinic Ifor Ian Iinfection Iin Ihis Ileft Ifoot. IWhich Iof Ithese Ifindings
Ishould Ithe Inurse I expect Ito Isee I during I an I assessment I of Ithis I patient?
Enlarged Iand Itender Iinguinal Inodes
The Inurse Iis Iexamining Ithe Ilymphatic Isystem Iof Ia Ihealthy I3-year-old Ichild. IWhich Ifinding Ishould
Ithe I nurse I expect?
Presence Iof Ipalpable Ilymph Inodes
During Ian Iassessment Iof Ian Iolder Iadult, Ithe Inurse Ishould Iexpect Ito Inotice Iwhich Ifinding Ias Ia
Inormal Iphysiologic I change I associated I with I the Iaging I process?
Peripheral Iblood Ivessels Igrowing Imore Irigid Iwith Iage, Iproducing Ia Irise Iin Isystolic Iblood
Ipressure
A I67-year-old Ipatient Istates Ithat Ihe Irecently Ibegan Ito Ihave Ipain Iin Ihis Ileft Icalf Iwhen Iclimbing Ithe
I10 Istairs Ito Ihis Iapartment. IThis Ipain Iis Irelieved Iby Isitting Ifor Iapproximately I2 Iminutes; Ithen Ihe Iis
Iable Ito Iresume Ihis Iactivities. IThe Inurse Iinterprets Ithat Ithis Ipatient Iis Imost Ilikely Iexperiencing:
Claudication.
A Ipatient Icomplains Iof Ileg Ipain Ithat Iwakes Ihim Iat Inight. IHe Istates Ithat Ihe I“has Ibeen Ihaving
Iproblems” Iwith Ihis Ilegs. IHe Ihas Ipain Iin Ihis Ilegs Iwhen Ithey Iare Ielevated Ithat Idisappears Iwhen
Ihe Idangles Ithem. IHe Irecently Inoticed I“a Isore” Ion Ithe Iinner I aspect Iof Ithe Iright Iankle. IOn Ithe
Ibasis Iof Ithis Ihealth Ihistory Iinformation, Ithe Inurse Iinterprets Ithat Ithe Ipatient Iis Imost Ilikely
Iexperiencing:
Problems Irelated Ito Iarterial Iinsufficiency.
During Ian Iassessment, Ithe Inurse Iuses Ithe Iprofile Isign Ito Idetect:
Early Iclubbing.
The Inurse Iis Iperforming Ian Iassessment Ion Ian Iadult. IThe Iadult’s Ivital Isigns Iare Inormal, Iand
Icapillary Irefill I time I is I 5 I seconds. I What I should I the Inurse I do I next?
Consider Ithis Ia Idelayed Icapillary Irefill Itime, Iand Iinvestigate Ifurther.
When Iassessing Ia Ipatient, Ithe Inurse Inotes Ithat Ithe Ileft Ifemoral Ipulse Ias Idiminished, I1+/4+.
IWhat I should Ithe I nurse I do Inext?
Auscultate Ithe Isite Ifor Ia Ibruit.
When Iperforming Ia Iperipheral Ivascular Iassessment Ion Ia Ipatient, Ithe Inurse Iis Iunable Ito IpalpateIthe
Iulnar Ipulses. IThe Ipatient’s Iskin Iis Iwarm Iand Icapillary Irefill Itime Iis Inormal. INext, Ithe Inurse Ishould:
Consider Ithis Ifinding Ias Inormal, Iand Iproceed Iwith Ithe Iperipheral Ivascular Ievaluation.
,The Inurse Iis Iassessing Ithe Ipulses Iof Ia Ipatient Iwho Ihas Ibeen Iadmitted Ifor Iuntreated
Ihyperthyroidism. IThe Inurse Ishould Iexpect Ito Ifind Ia(n) pulse.
Bounding
The Inurse Iis Ipreparing Ito Iperform Ia Imodified IAllen Itest. IWhich Iis Ian Iappropriate Ireason Ifor Ithis
Itest?
To Ievaluate Ithe Iadequacy Iof Icollateral Icirculation Ibefore Icannulating Ithe Iradial Iartery
A Ipatient Ihas Ibeen Idiagnosed Iwith Ivenous Istasis. IWhich Iof Ithese Ifindings Iwould Ithe
Inurse Imost Ilikely I observe?
Brownish Idiscoloration Ito Ithe Iskin Iof Ithe Ilower Ileg
The Inurse Iis Iattempting Ito Iassess Ithe Ifemoral Ipulse Iin Ia Ipatient Iwho Iis Iobese. IWhich Iof Ithese
Iactions I would I be I most I appropriate?
The Ipatient Iis Iasked Ito Ibend Ihis Ior Iher Iknees Ito Ithe Iside Iin Ia Ifroglike Iposition.
When Iauscultating Iover Ia Ipatient’s Ifemoral Iarteries, Ithe Inurse Inotices Ithe Ipresence Iof Ia Ibruit Ion
Ithe I left I side. I The I nurse I knows I that I bruits:
Occur Iwith Iturbulent Iblood Iflow, Iindicating Ipartial Iocclusion.
How Ishould Ithe Inurse Idocument Imild, Islight Ipitting Iedema Ithe Iankles Iof Ia Ipregnant Ipatient?
1+/0-4+
I
A Ipatient Ihas Ihard, Inonpitting Iedema Iof Ithe Ileft Ilower Ileg Iand Iankle. IThe Iright Ileg Ihas Ino
Iedema. I Based I on I these Ifindings, I the I nurse Irecalls I that:
Nonpitting, Ihard Iedema Ioccurs Iwith Ilymphatic Iobstruction.
When Iassessing Ia Ipatient’s Ipulse, Ithe Inurse Inotes Ithat Ithe Iamplitude Iis Iweaker Iduring
Iinspiration Iand Istronger Iduring Iexpiration. IWhen Ithe Inurse Imeasures Ithe Iblood Ipressure, Ithe
Ireading Idecreases I20 Imm IHg Iduring Iinspiration Iand Iincreases Iwith Iexpiration. IThis Ipatient Iis
Iexperiencing I pulsus:
Paradoxus.
During Ian Iassessment, Ithe Inurse Ihas Ielevated Ia Ipatient’s Ilegs I12 Iinches Ioff Ithe Itable Iand Ihas
Ihad Ihim Iwag Ihis Ifeet Ito Idrain Ioff Ivenous Iblood. IAfter Ihelping Ihim Isit Iup Iand Idangle Ihis Ilegs Iover
Ithe Iside Iof Ithe Itable, I the Inurse Ishould I expect Ithat Ia Inormal Ifinding I at I this Ipoint I would Ibe:
Venous Ifilling Iwithin I15 Iseconds.
, During Ia Ivisit Ito Ithe Iclinic, Ia Iwoman Iin Iher Iseventh Imonth Iof Ipregnancy Icomplains Ithat Iher Ilegs
Ifeel I“heavy Iin Ithe Icalf” Iand Ithat Ishe Ioften Ihas Ifoot Icramps Iat I night. IThe Inurse Inotices Ithat Ithe
Ipatient Ihas Idilated, Itortuous Iveins Iapparent Iin Iher Ilower Ilegs. IWhich Icondition Iis Ireflected Iby
Ithese Ifindings?
Varicose Iveins
During Ian Iassessment, Ithe Inurse Inotices Ithat Ia Ipatient’s Ileft Iarm Iis Iswollen Ifrom Ithe Ishoulder
Idown Ito Ithe Ifingers, Iwith Inonpitting Ibrawny Iedema. IThe Iright Iarm Iis Inormal. IThe Ipatient Ihad Ia
Ileft-sided I mastectomy I 1 Iyear I ago. I The I nurse I suspects Iwhich I problem?
Lymphedema
The Inurse Iis Ipreparing Ito Iassess Ithe Iankle-brachial Iindex I(ABI) Iof Ia Ipatient. IWhich Istatement
Iabout I the I ABI I is I true?
An IABI Iof I0.9 Ito I0.7 Iindicates Ithe Ipresence Iof Iperipheral Ivascular Idisease Iand Imild Iclaudication.
The Inurse Iis Iperforming Ia Iwell-child Icheckup Ion Ia I5-year-old Iboy. IHe Ihas Ino Icurrent Icondition
Ithat Iwould Ilead Ithe Inurse Ito Isuspect I an Iillness. IHis Ihealth Ihistory Iis Iunremarkable, I and Ihe
Ireceived Iimmunizations I1 Iweek Iago. IWhich Iof Ithese Ifindings Ishould Ibe Iconsidered Inormal Iin
Ithis Ipatient?
Palpable Ifirm, Ismall, Ishotty, Imobile, Iand Inontender Ilymph Inodes
When Iusing Ia IDoppler Iultrasonic Istethoscope, Ithe Inurse Irecognizes Ivenous Iflow Iwhen Iwhich
Isound I is I heard?
Swishing, Iwhooshing Isound
The Inurse Iis Idescribing Ia Iweak, Ithready Ipulse Ion Ithe Idocumentation Iflow Isheet. IWhich
Istatement I is I correct?
“Is Ihard Ito Ipalpate, Imay Ifade Iin Iand Iout, Iand Iis Ieasily Iobliterated Iby Ipressure.”
During Ian Iassessment, Ia Ipatient Itells Ithe Inurse Ithat Iher Ifingers Ioften Ichange Icolor Iwhen
Ishe Igoes Iout Iin I cold Iweather. IShe Idescribes Ithese Iepisodes Ias Iher Ifingers Ifirst Iturning
Iwhite, Ithen Iblue, Ithen I red Iwith Ia Iburning, Ithrobbing Ipain. IThe Inurse Isuspects Ithat Ishe Iis
Iexperiencing:
Raynaud Idisease.
During Ia Iroutine Ioffice Ivisit, Ia Ipatient Itakes Ioff Ihis Ishoes Iand Ishows Ithe Inurse I“this Iawful Isore
Ithat Iwon’t Iheal.” IOn Iinspection, Ithe Inurse Inotes Ia I3-cm Iround Iulcer Ion Ithe Ileft Igreat Itoe, Iwith Ia
Ipale Iischemic Ibase, Iwell-defined Iedges, Iand Ino Idrainage. IThe Inurse Ishould Iassess Ifor Iother
Isigns I and I symptoms I of:
Arterial Iischemic Iulcer.
