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NR 304 / NR304 EXAM TESTBANK. QUESTIONS WITH 100% CORRECT ANSWERS
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- NR 304
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- Chamberlain College Nursing
NR 304 EXAM TEST BANK. Jarvis: Physical Examination & Health Assessment, 7th Edition
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NR 304 EXAM TEST BANK. Chapter 21 Jarvis: Physical Examination & Health Assessment, 7th Edition 1.Which statement is true regarding the arterial system? The arterial system is a high -pressure system. 2. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _ artery. Brachial 3. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? Lateral to the extensor tendon of the great toe 4. A 65 -year -old patient is experiencing pain in his left calf when he e xercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with ___ the left leg. Ischemia caused by a partial block age of an artery supplying 5. The nurse is reviewing venous blood flow patterns. W hich of these statements best describes the mechanism(s) by which venous blood returns to the heart? Intraluminal valves ensure unidirectional flow toward the heart 6. Which vein(s ) is(are) responsible for most of the venous return in the arm? Superficial 7. A 70-year -old patient is scheduled for open -heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, “What happens to my c irculation when this vein is removed?” The nurse should reply: “This vein can b e removed without harming your circulation because the deeper veins in your leg are in good condition.” 8. The nurse is reviewing the risk factors for venous disease. Which of thes e situations best describes a person at highest risk for the development of ven ous disease? Person who has been on bed rest for 4 days 9. The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material w ith which statement? “The flow of lymph is slow, compared with that of the bloo d.” 10. When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? Examine the patient’s lower arm and hand, and check for the presence of infection or lesions. 11. A 35 -year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? Enlarged and te nder inguinal nodes 12. The nurse is examining the lymphatic system of a healthy 3 -year -old child. Which finding should the nurse expect? Presence of palpable lymph nodes 13. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? Peripheral blo od vessels growing more rigid with age, producing a rise in systolic blood pressure 14. 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 approxi mately 2 minutes; then he is able to resume his activities. The nurse interprets that th is patient is most likely experiencing: Claudication. 15. A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his leg s. 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 like ly experiencing: Problems related to arterial insufficiency. 16. During an assessment, the n urse uses the profile sign to detect: Early clubbing. 17. The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time i s 5 seconds. What should the nurse do next? Consider this a delayed capillary refill tim e, and investigate further. 18. When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? Auscultate the s ite for a bruit. 19. 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 pr oceed with the pe ripheral vascular evaluation. 21. The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) ___ pulse. Bounding 22. The nurse is preparing to perform a modified Allen t est. Which is an appropriate reason for this test? To evaluate the adequacy of collateral circulation before cannulating the radial artery 23. A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? Brownis h discoloration to the skin of the lower leg 24. The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? The patient is asked to bend his or her knees to the side in a froglike position. 25. When auscultating over a patient’s femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruit s: Occur with turbulent blood flow, indicating partial occlusion. 26. How should the nurse document mild, slight pitting oedema the ankles of a pregnant patient? 1+/0 -4+ 27. A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no oedema . Based on these findings, the nurse recalls that: Nonpitting, hard edema occurs with lymphatic obstruction. 28. assessing a patient’s pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nur se measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. Th is patient is experiencing pulsus: Paradoxus. 29. During an assessment, the nurse has elevated a patient’s legs 12 inches off the table and has h ad him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be: Venous filling within 15 seconds. 30. During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel “heavy in the calf” and that she often has foo t cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? Varicose veins 31. During an assessment, the nurse notices that a patient’s left arm is swollen from t he shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left -sided mastectomy 1 year ago. T he nurse suspects which problem? Lymphedema 32. The nurse is preparing to assess the ankle -brachial index (ABI) of a pa tient. Which statement about the ABI is true? An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudicatio n. 33. The nurse is performing a well -child checkup on a 5 -year -old boy. He has no current condition that would lead th e nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should b e considered normal in this patient? Palpable firm, small, shotty, mobile, and nontender lymph nodes 34. When using a D oppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? Swishing, whooshing sound 35. The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? “Is hard to palpate, may fade in and out, and is easily obliterated by pressure.” 36. During an assessment, a patient tells the nurse that her fingers of ten change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red wi th a burning, throbbing pain. The nurse suspects that she is experiencing: Raynaud disease. 37. During a routine office v isit, a patient takes off his shoes and shows the nurse “this awful sore that won’t heal.” On inspection, the nurse notes a 3 -cm round ulce r on the left great toe, with a pale ischemic base, well -defined edges, and no drainage. The nurse should assess for other signs and symptoms of: Arterial ischemic ulcer. 38. The nurse is reviewing an assessment of a patient’s peripheral pulses and notices tha t the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what typ e of pulse? Normal 39. A patient is recovering from several hours of orthopaedic surgery. During an assessment of the patient’s lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. Intense, sharp pain, with the deep muscle tender to the touch Sudden onsetThe benefits of buying summaries with Stuvia:
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