NR304 FINAL EXAM
NR304 HEALTH ASSESSMENT II FINAL
EXAM QUESTIONS AND ANSWERS
palpation of radial pulse - Palpate both pulses noting the rate, rhythm, elasticity of vessel
wall and equal force
grading pulse - 3+ full bounding
2+ normal
1+ weak
0 absent
brachial pulse - palpate this pulse if you suspect arterial insufficiency
modified Allen's test - tests for ulnar arterial insufficiency by occluding both the radial
and ulnar artery
normal results: normal color of hand should reappear approximately 2-5 seconds
abnormal results: pallor persists or a sluggish return to color suggest occlusion of the
collateral arterial flow
temporal artery - palpated in front of the ear
carotid artery - palpated in the groove b/t the sternomastoid muscle and the trachea
brachial artery - major artery supplying the arm
radial artery - lies medial to the radius and wrist supplies blood to the hand
NR304 FINAL EXAM
,NR304 FINAL EXAM
ulnar artery - lies lateral to the ulna. Deeper and often difficult to feel. Supplies blood to
the hand
femoral artery - major artery in the leg. Palpated in the inguinal area
popliteal artery - artery in the knee. Located posterior to the patella. Divides into the
anterior and posterial tibial artery
anterior tibial - travels down the front of the leg on to the dorsal of the foot becomes the
dorsalis pedis.
carries blood to the anterior compartment of the leg and dorsal surface of the foot
posterior tibial - travels down behind the medial malleolus and forms the plantar arteries
in the foot.
carries blood to the posterior compartment of the leg and plantar surface of the foot
dorsalis pedis - a blood vessel of the lower limb that carries oxygenated blood to the
dorsal surface of the foot
claudication distance - the number of blocks walked or stairs climbed to produce pain
arterial claudication - pain in the calf, thigh or hip or muscle fatigue that occurs when
walking a certain distance related to peripheral arterial disease (PAD)
peripheral perfusion - checking for capillary refill by blanching the nail beds and noting
the time for color return
normal is less than 1-2 seconds
NR304 FINAL EXAM
,NR304 FINAL EXAM
doppler - used if pulses are too weak to detect by palpation, monitor blood pressure in
infants or children, measure low blood pressure or blood pressure in the lower extremities
A noninvasive test using sound waves to detect blood flow through blood vessels
ex. competent valves (varicosities)
edema - fluid build up in the interstitial space
PVD - circulation disorder in which narrowed blood vessels reduce blood flow to the
limbs. Caused by arteriosclerosis (hardening of arteries caused by plaque build up)
Inspect skin for ulcers, temperature and color
lymphedema - swelling in the arms or legs caused by a blockage of the lymphatic system
, causes a build up of lymph fluid in tissues
intermittent claudication - a condition in which cramping pain in the leg is induced by
exercise, typically caused by obstruction of the arteries
5 P's - Pain
Pulselessness
Pallor
Parasthesia (can't feel)
Paralysis (can't move)
Grading Edema - +1 mild pitting, no swelling
+2 moderate pulling, indentation goes away quickly
+3 deep pitting, swollen
NR304 FINAL EXAM
, NR304 FINAL EXAM
+4 very deep pitting, indentation stays, very swollen
Arterial Occlusion - -5 P's
-Mottling
- Bluish/cyanosis
- decrease capillary refill
- cold temperature
arterial insufficiency - - skin is cool
-skin is thin and shiny
- no edema
-no hair growth
- decreased pulses
-yellow toenails
-dependent rubor (ruddy red/blue)
-elevated pallor
venous insufficiency - - normal temperature
-normal pulse
-flaky, dry, thick skin
-skin tears easily- friable
-edema
-brawny color
arterial ulcers - -intermittent claudication pain
-no edema
NR304 FINAL EXAM
NR304 HEALTH ASSESSMENT II FINAL
EXAM QUESTIONS AND ANSWERS
palpation of radial pulse - Palpate both pulses noting the rate, rhythm, elasticity of vessel
wall and equal force
grading pulse - 3+ full bounding
2+ normal
1+ weak
0 absent
brachial pulse - palpate this pulse if you suspect arterial insufficiency
modified Allen's test - tests for ulnar arterial insufficiency by occluding both the radial
and ulnar artery
normal results: normal color of hand should reappear approximately 2-5 seconds
abnormal results: pallor persists or a sluggish return to color suggest occlusion of the
collateral arterial flow
temporal artery - palpated in front of the ear
carotid artery - palpated in the groove b/t the sternomastoid muscle and the trachea
brachial artery - major artery supplying the arm
radial artery - lies medial to the radius and wrist supplies blood to the hand
NR304 FINAL EXAM
,NR304 FINAL EXAM
ulnar artery - lies lateral to the ulna. Deeper and often difficult to feel. Supplies blood to
the hand
femoral artery - major artery in the leg. Palpated in the inguinal area
popliteal artery - artery in the knee. Located posterior to the patella. Divides into the
anterior and posterial tibial artery
anterior tibial - travels down the front of the leg on to the dorsal of the foot becomes the
dorsalis pedis.
carries blood to the anterior compartment of the leg and dorsal surface of the foot
posterior tibial - travels down behind the medial malleolus and forms the plantar arteries
in the foot.
carries blood to the posterior compartment of the leg and plantar surface of the foot
dorsalis pedis - a blood vessel of the lower limb that carries oxygenated blood to the
dorsal surface of the foot
claudication distance - the number of blocks walked or stairs climbed to produce pain
arterial claudication - pain in the calf, thigh or hip or muscle fatigue that occurs when
walking a certain distance related to peripheral arterial disease (PAD)
peripheral perfusion - checking for capillary refill by blanching the nail beds and noting
the time for color return
normal is less than 1-2 seconds
NR304 FINAL EXAM
,NR304 FINAL EXAM
doppler - used if pulses are too weak to detect by palpation, monitor blood pressure in
infants or children, measure low blood pressure or blood pressure in the lower extremities
A noninvasive test using sound waves to detect blood flow through blood vessels
ex. competent valves (varicosities)
edema - fluid build up in the interstitial space
PVD - circulation disorder in which narrowed blood vessels reduce blood flow to the
limbs. Caused by arteriosclerosis (hardening of arteries caused by plaque build up)
Inspect skin for ulcers, temperature and color
lymphedema - swelling in the arms or legs caused by a blockage of the lymphatic system
, causes a build up of lymph fluid in tissues
intermittent claudication - a condition in which cramping pain in the leg is induced by
exercise, typically caused by obstruction of the arteries
5 P's - Pain
Pulselessness
Pallor
Parasthesia (can't feel)
Paralysis (can't move)
Grading Edema - +1 mild pitting, no swelling
+2 moderate pulling, indentation goes away quickly
+3 deep pitting, swollen
NR304 FINAL EXAM
, NR304 FINAL EXAM
+4 very deep pitting, indentation stays, very swollen
Arterial Occlusion - -5 P's
-Mottling
- Bluish/cyanosis
- decrease capillary refill
- cold temperature
arterial insufficiency - - skin is cool
-skin is thin and shiny
- no edema
-no hair growth
- decreased pulses
-yellow toenails
-dependent rubor (ruddy red/blue)
-elevated pallor
venous insufficiency - - normal temperature
-normal pulse
-flaky, dry, thick skin
-skin tears easily- friable
-edema
-brawny color
arterial ulcers - -intermittent claudication pain
-no edema
NR304 FINAL EXAM
