NR304- Exam 1 Adapts Week 1-3
A client living with peripheral arterial disease (PAD) in the lower extremities asks the
nurse what causes their pain at rest. What is the best response provided by the nurse?
"Disease in the arteries causes decreased arterial blood flow to the nerves in your legs."
"The cause is a vasospasm of small cutaneous arteries in the feet."
"An increase in retrograde venous blood flow in the legs puts pressure on the arteries."
"Your muscles do not get enough arterial blood when you exercise. When you rest, the
blood flow increases, causing the pain you feel." - answer"Disease in the arteries
causes decreased arterial blood flow to the nerves in your legs."
The nurse caring for a client hospitalized with infective endocarditis is told by an
unlicensed assistive personnel (UAP) that the client is reporting sudden left leg pain
with pallor, paresthesia, and a loss of peripheral pulses. What action should the nurse
take first?
Start anticoagulant therapy with IV heparin.
Elevate the leg to promote venous return.
Notify the client's healthcare provider of the change in peripheral perfusion.
Complete a focused neurovascular assessment. - answerComplete a focused
neurovascular assessment.
Which observed assessment finding of the lower extremities may result from a
peripheral vascular disorder? - answerThe skin is red in color, with peeling skin and
sores.
The nurse is assessing an adult client who is 5' 5" (165.1 cm), weighs 209 lb (95 kg),
and has a history of tobacco use, hypertension, high sodium intake, a sedentary
lifestyle, and a family history of cardiovascular disease (CVD). When planning care, the
nurse determines that the client should prioritize modifying which two risk factors for
peripheral artery disease?
Sodium intake
Family history of CVD
Sedentary lifestyle
Weight
Tobacco use - answerWeight
Tobacco use
Which clinical manifestations do clients with Buerger's disease and those with
Raynaud's phenomenon have in common? Select all that apply.
Intermittent fevers
,Sensitivity to cold temperatures
Gangrenous ulcers on fingertips
Color changes of fingers and toes
Episodes of superficial vein thrombosis - answerSensitivity to cold temperatures
Gangrenous ulcers on fingertips
Color changes of fingers and toes
Which client is at the highest risk of developing deep vein thrombosis (DVT)?
A 26-year-old woman who is 3 days postpartum and received maintenance IV fluids
during 12 hours of labor
A 72-year-old man at home who walks hourly while recovering from prostate surgery
A 38-year-old woman who smokes, takes oral contraceptives, and is flying across the
Atlantic Ocean soon
A 62-year-old man with spider veins who is having arthroscopic knee surgery - answerA
38-year-old woman who smokes, takes oral contraceptives, and is flying across the
Atlantic Ocean soon
he nurse ascultates a heart murmur that was not previously documented. What
additional questions will the nurse ask the client related to the murmur? Select all that
apply.
"When was your last chest x-ray?"
"How long has your foot been cool to the touch?"
"Have you ever been told you have a heart murmur?"
"Do you have a history of cardiac valve disease?"
"Have you ever had an electrocardiogram?" - answer"Have you ever been told you have
a heart murmur?"
"Do you have a history of cardiac valve disease?"
The oncoming caregiver is entering the room for the first time. What is the current
priority assessment?
Peripheral circulation
Pain
Vital signs
Heart rate - answerPain
The examiner's assessment of Mr. Ayo's lower extremities confirms that his right foot is
cool to the touch with absent posterior tibial and dorsalis pedis pulses. What additional
objective data is collected related to circulation during a focused assessment? Select all
that apply.
Swelling of feet and ankles
Location and timing of pain
Absence of hair on toes
, Presence of ulcers
Type of shoes worn - answerSwelling of feet and ankles
Location and timing of pain
Absence of hair on toes
Presence of ulcers
Based on subjective and objective assessment data, the nurse hypothesizes that the
changes in the right foot are due to which alteration in health?
Peripheral venous disease
Diabetic neuropathy
Peripheral arterial disease
Normal variation for age - answerPeripheral arterial disease
The unlicensed assistive personnel (UAP) reports to the nurse that a client is reporting
pain and tingling in their right hand that started about 10 minutes ago. The nurse knows
the client had an arterial blood gas (ABG) sample taken from their right brachial artery
within the past 20 minutes. Which additional assessment data should the nurse
anticipate if this client is experiencing an acute arterial occlusion related to ABG? Select
all that apply.
The right hand is cool to the touch.
Loss of finger movement occurs on the right hand.
Pain is worse in the fingertips of the impacted hand.
Tingling occurs in the right fingers and palm.
An absence of right carotid pulse occurs.
Pallor appears in bilateral arms. - answerPain is worse in the fingertips of the impacted
hand.
Tingling occurs in the right fingers and palm.
The right hand is cool to the touch.
An examiner documenting the assessment of the wound pictured here includes which
descriptive words or phrases? Select all that apply.
Irregular edges
Lateral malleolus
Varicose veins
Edema
Diffuse discoloration - answerDiffuse discoloration
Varicose veins
Irregular edges
Based on the cues pictured in this image, the examiner hypothesizes this health
alteration is a result of what pathologic condition?
A client living with peripheral arterial disease (PAD) in the lower extremities asks the
nurse what causes their pain at rest. What is the best response provided by the nurse?
"Disease in the arteries causes decreased arterial blood flow to the nerves in your legs."
"The cause is a vasospasm of small cutaneous arteries in the feet."
"An increase in retrograde venous blood flow in the legs puts pressure on the arteries."
"Your muscles do not get enough arterial blood when you exercise. When you rest, the
blood flow increases, causing the pain you feel." - answer"Disease in the arteries
causes decreased arterial blood flow to the nerves in your legs."
The nurse caring for a client hospitalized with infective endocarditis is told by an
unlicensed assistive personnel (UAP) that the client is reporting sudden left leg pain
with pallor, paresthesia, and a loss of peripheral pulses. What action should the nurse
take first?
Start anticoagulant therapy with IV heparin.
Elevate the leg to promote venous return.
Notify the client's healthcare provider of the change in peripheral perfusion.
Complete a focused neurovascular assessment. - answerComplete a focused
neurovascular assessment.
Which observed assessment finding of the lower extremities may result from a
peripheral vascular disorder? - answerThe skin is red in color, with peeling skin and
sores.
The nurse is assessing an adult client who is 5' 5" (165.1 cm), weighs 209 lb (95 kg),
and has a history of tobacco use, hypertension, high sodium intake, a sedentary
lifestyle, and a family history of cardiovascular disease (CVD). When planning care, the
nurse determines that the client should prioritize modifying which two risk factors for
peripheral artery disease?
Sodium intake
Family history of CVD
Sedentary lifestyle
Weight
Tobacco use - answerWeight
Tobacco use
Which clinical manifestations do clients with Buerger's disease and those with
Raynaud's phenomenon have in common? Select all that apply.
Intermittent fevers
,Sensitivity to cold temperatures
Gangrenous ulcers on fingertips
Color changes of fingers and toes
Episodes of superficial vein thrombosis - answerSensitivity to cold temperatures
Gangrenous ulcers on fingertips
Color changes of fingers and toes
Which client is at the highest risk of developing deep vein thrombosis (DVT)?
A 26-year-old woman who is 3 days postpartum and received maintenance IV fluids
during 12 hours of labor
A 72-year-old man at home who walks hourly while recovering from prostate surgery
A 38-year-old woman who smokes, takes oral contraceptives, and is flying across the
Atlantic Ocean soon
A 62-year-old man with spider veins who is having arthroscopic knee surgery - answerA
38-year-old woman who smokes, takes oral contraceptives, and is flying across the
Atlantic Ocean soon
he nurse ascultates a heart murmur that was not previously documented. What
additional questions will the nurse ask the client related to the murmur? Select all that
apply.
"When was your last chest x-ray?"
"How long has your foot been cool to the touch?"
"Have you ever been told you have a heart murmur?"
"Do you have a history of cardiac valve disease?"
"Have you ever had an electrocardiogram?" - answer"Have you ever been told you have
a heart murmur?"
"Do you have a history of cardiac valve disease?"
The oncoming caregiver is entering the room for the first time. What is the current
priority assessment?
Peripheral circulation
Pain
Vital signs
Heart rate - answerPain
The examiner's assessment of Mr. Ayo's lower extremities confirms that his right foot is
cool to the touch with absent posterior tibial and dorsalis pedis pulses. What additional
objective data is collected related to circulation during a focused assessment? Select all
that apply.
Swelling of feet and ankles
Location and timing of pain
Absence of hair on toes
, Presence of ulcers
Type of shoes worn - answerSwelling of feet and ankles
Location and timing of pain
Absence of hair on toes
Presence of ulcers
Based on subjective and objective assessment data, the nurse hypothesizes that the
changes in the right foot are due to which alteration in health?
Peripheral venous disease
Diabetic neuropathy
Peripheral arterial disease
Normal variation for age - answerPeripheral arterial disease
The unlicensed assistive personnel (UAP) reports to the nurse that a client is reporting
pain and tingling in their right hand that started about 10 minutes ago. The nurse knows
the client had an arterial blood gas (ABG) sample taken from their right brachial artery
within the past 20 minutes. Which additional assessment data should the nurse
anticipate if this client is experiencing an acute arterial occlusion related to ABG? Select
all that apply.
The right hand is cool to the touch.
Loss of finger movement occurs on the right hand.
Pain is worse in the fingertips of the impacted hand.
Tingling occurs in the right fingers and palm.
An absence of right carotid pulse occurs.
Pallor appears in bilateral arms. - answerPain is worse in the fingertips of the impacted
hand.
Tingling occurs in the right fingers and palm.
The right hand is cool to the touch.
An examiner documenting the assessment of the wound pictured here includes which
descriptive words or phrases? Select all that apply.
Irregular edges
Lateral malleolus
Varicose veins
Edema
Diffuse discoloration - answerDiffuse discoloration
Varicose veins
Irregular edges
Based on the cues pictured in this image, the examiner hypothesizes this health
alteration is a result of what pathologic condition?
