HA EXAM 2 QUESTIONS AND ANSWERS
A 75-year-old woman who has a history of diabetes and peripheral vascular disease
has been trying to remove a corn on the bottom of her foot with a pair of scissors. The
nurse will encourage her to stop trying to remove the corn with scissors because:
the woman could be at increased risk for infection and lesions because of her chronic
disease.
A patient comes in for a physical, and she complains of "freezing to death" while waiting
for her examination. The nurse notes that her skin is pale and cool and attributes this
finding to:
peripheral vasoconstriction.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner
chair for about 3 days with his feet down and he wants the nurse to evaluate his feet.
During the assessment, the nurse might expect to find:
distended veins.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up
appointment. On assessment, the nurse might expect to see which assessment finding?
Clubbing of the nails
The nurse is assessing the skin of a patient who has AIDS and notices multiple patch-
like lesions on the temple and beard area that are faint pink in color. The nurse
recognizes these lesions as:
Kaposi's sarcoma.
Kaposi's sarcoma is a vascular tumor that, in early stages, appears as multiple, patch-
like, faint pink lesions over the patient's temple and beard areas. Measles is
characterized by a red-purple maculopapular blotchy rash which appears on third or
fourth day of illness. Rash appears first behind ears and spreads over face, then over
neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth,
slightly raised bright red dots that commonly appear on the trunk in all adults over 30
years old. Herpes zoster causes vesicles that are elevated with a cavity containing clear
fluid, up to 1 cm in size.
,While performing an assessment of a 65-year-old man with a history of hypertension
and coronary artery disease, the nurse notices the presence of pitting edema in the
lower legs bilaterally. The skin is puffy and tight but of normal color. There is no
increased redness or tenderness over his lower legs, and the peripheral pulses are
equal and strong. In this situation, the nurse suspects that the likely cause of the edema
would be:
Heart failure.
A 40-year-old woman reports a change in mole size, accompanied by color changes,
itching, burning, and bleeding over the past month. She has a dark complexion and has
no family history of skin cancer, but she has had many blistering sunburns in the past.
The nurse would:
Refer the patient because of the suspicion of melanoma on the basis of her symptoms.
The ABCD danger signs of melanoma are asymmetry, border irregularity, color
variation, and diameter. In addition, individuals may report a change in size,
development of itching, burning, bleeding, or a new-pigmented lesion. Any of these
signs raise suspicion of malignant melanoma and warrant immediate referral.
The nurse is assessing for clubbing of the fingernails and would expect to find:
an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a
central red ulcer. She said she first noticed it several months ago and that it has slowly
grown larger. The nurse suspects which condition?
Basal cell carcinoma
A 67-year-old patient states that he recently began to have pain in his left calf when
climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately
2 minutes; then he is able to resume his activities. The nurse interprets that this patient
is most likely experiencing:
Claudication
* A patient complains of leg pain that wakes him at night. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing:
Problems related to arterial insufficiency.
, During an assessment, the nurse uses the profile sign to detect
Early clubbing
The nurse is performing an assessment on an adult. The adult's vital signs are normal,
and capillary refill time is 5 seconds. What should the nurse do next?
Consider this a delayed capillary refill time, and investigate further
When assessing a patient, the nurse notes that the left femoral pulse as diminished,
1+/4+. What should the nurse do next?
Auscultate the site for a bruit
When performing a peripheral vascular assessment on a patient, the nurse is unable to
palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal.
Next, the nurse should:
Consider this finding as normal, and proceed with the peripheral vascular evaluation.
* A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe?
Brownish discoloration to the skin of the lower leg
When auscultating over a patient's femoral arteries, the nurse notices the presence of a
bruit on the left side. The nurse knows that bruits:
Occur with turbulent blood flow, indicating partial occlusion.
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has
no edema. Based on these findings, the nurse recalls that:
Nonpitting, hard edema occurs with lymphatic obstruction.
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when
which sound is heard?
Swishing, whooshing sound
During an assessment, a patient tells the nurse that her fingers often change color when
she goes out in cold weather. She describes these episodes as her fingers first turning
white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is
experiencing:
Raynaud disease.
A 75-year-old woman who has a history of diabetes and peripheral vascular disease
has been trying to remove a corn on the bottom of her foot with a pair of scissors. The
nurse will encourage her to stop trying to remove the corn with scissors because:
the woman could be at increased risk for infection and lesions because of her chronic
disease.
A patient comes in for a physical, and she complains of "freezing to death" while waiting
for her examination. The nurse notes that her skin is pale and cool and attributes this
finding to:
peripheral vasoconstriction.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner
chair for about 3 days with his feet down and he wants the nurse to evaluate his feet.
During the assessment, the nurse might expect to find:
distended veins.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up
appointment. On assessment, the nurse might expect to see which assessment finding?
Clubbing of the nails
The nurse is assessing the skin of a patient who has AIDS and notices multiple patch-
like lesions on the temple and beard area that are faint pink in color. The nurse
recognizes these lesions as:
Kaposi's sarcoma.
Kaposi's sarcoma is a vascular tumor that, in early stages, appears as multiple, patch-
like, faint pink lesions over the patient's temple and beard areas. Measles is
characterized by a red-purple maculopapular blotchy rash which appears on third or
fourth day of illness. Rash appears first behind ears and spreads over face, then over
neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth,
slightly raised bright red dots that commonly appear on the trunk in all adults over 30
years old. Herpes zoster causes vesicles that are elevated with a cavity containing clear
fluid, up to 1 cm in size.
,While performing an assessment of a 65-year-old man with a history of hypertension
and coronary artery disease, the nurse notices the presence of pitting edema in the
lower legs bilaterally. The skin is puffy and tight but of normal color. There is no
increased redness or tenderness over his lower legs, and the peripheral pulses are
equal and strong. In this situation, the nurse suspects that the likely cause of the edema
would be:
Heart failure.
A 40-year-old woman reports a change in mole size, accompanied by color changes,
itching, burning, and bleeding over the past month. She has a dark complexion and has
no family history of skin cancer, but she has had many blistering sunburns in the past.
The nurse would:
Refer the patient because of the suspicion of melanoma on the basis of her symptoms.
The ABCD danger signs of melanoma are asymmetry, border irregularity, color
variation, and diameter. In addition, individuals may report a change in size,
development of itching, burning, bleeding, or a new-pigmented lesion. Any of these
signs raise suspicion of malignant melanoma and warrant immediate referral.
The nurse is assessing for clubbing of the fingernails and would expect to find:
an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a
central red ulcer. She said she first noticed it several months ago and that it has slowly
grown larger. The nurse suspects which condition?
Basal cell carcinoma
A 67-year-old patient states that he recently began to have pain in his left calf when
climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately
2 minutes; then he is able to resume his activities. The nurse interprets that this patient
is most likely experiencing:
Claudication
* A patient complains of leg pain that wakes him at night. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing:
Problems related to arterial insufficiency.
, During an assessment, the nurse uses the profile sign to detect
Early clubbing
The nurse is performing an assessment on an adult. The adult's vital signs are normal,
and capillary refill time is 5 seconds. What should the nurse do next?
Consider this a delayed capillary refill time, and investigate further
When assessing a patient, the nurse notes that the left femoral pulse as diminished,
1+/4+. What should the nurse do next?
Auscultate the site for a bruit
When performing a peripheral vascular assessment on a patient, the nurse is unable to
palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal.
Next, the nurse should:
Consider this finding as normal, and proceed with the peripheral vascular evaluation.
* A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe?
Brownish discoloration to the skin of the lower leg
When auscultating over a patient's femoral arteries, the nurse notices the presence of a
bruit on the left side. The nurse knows that bruits:
Occur with turbulent blood flow, indicating partial occlusion.
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has
no edema. Based on these findings, the nurse recalls that:
Nonpitting, hard edema occurs with lymphatic obstruction.
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when
which sound is heard?
Swishing, whooshing sound
During an assessment, a patient tells the nurse that her fingers often change color when
she goes out in cold weather. She describes these episodes as her fingers first turning
white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is
experiencing:
Raynaud disease.
