NR 304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26 / NR304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26: LATEST,CHAMBERLAIN COLLEGE OF NURSING
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NR 304 (NR304)
Institution
CHAMBERLAIN COLLEGE OF NURSING
NR 304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26 / NR304 EXAM 1 COMLETE SOLUTIONS ch-5 to 26: LATEST,CHAMBERLAIN COLLEGE OF NURSINGNR 304 STUDY GUIDE EXAM 1 comlte solutions ch-5 to 26
Chapter 21
Jarvis: Physical Examination & Health Assessment, 7th Edition 1.Which statement is true regarding the art...
NR 304 EXAM 1 COMLETE SOLUTIONS
(CHAPTERS 5 TO 26)
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.
The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _
artery.
Brachial
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
A 65-year-old patient is experiencing pain in his left calf when he exercises 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 blockage of an artery supplying
The nurse is reviewing venous blood flow patterns. Which of these statements best describes
the mechanism(s) by which venous blood returns to the heart?
Intraluminal valves ensure unidirectional flow toward the heart
Which vein(s) is(are) responsible for most of the venous return in the arm?
Superficial
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
circulation when this vein is removed?” The nurse should reply:
“This vein can be removed without harming your circulation because the deeper veins in your
leg are in good condition.”
The nurse is reviewing the risk factors for venous disease. Which of these situations best
describes a person at highest risk for the development of venous disease?
Person who has been on bed rest for 4 days
The nurse is teaching a review class on the lymphatic system. A participant shows correct
understanding of the material with which statement?
“The flow of lymph is slow, compared with that of the blood.”
,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.
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 tender inguinal nodes
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
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 blood vessels growing more rigid with age, producing a rise in systolic blood
pressure
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.
,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
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this
test?
To evaluate the adequacy of collateral circulation before cannulating the radial artery
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
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.
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.
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
1+/0-4+
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 assessing a patient’s pulse, the nurse notes that the amplitude is weaker during
inspiration and stronger during expiration. When the nurse measures the blood pressure, the
reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is
experiencing pulsus:
Paradoxus.
During an assessment, the nurse has elevated a patient’s legs 12 inches off the table and has
had 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.
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 foot 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
During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder
down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a
left-sided mastectomy 1 year ago. The nurse suspects which problem?
Lymphedema
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement
about the ABI is true?
An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.
The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition
that would lead the nurse to suspect an illness. His health history is unremarkable, and he
received immunizations 1 week ago. Which of these findings should be considered normal in
this patient?
Palpable firm, small, shotty, mobile, and nontender lymph nodes
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which
sound is heard?
Swishing, whooshing sound
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.”
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.
During a routine office visit, 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 ulcer 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.
The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the
documentation states that the radial pulses are “2+.” The nurse recognizes that this reading
indicates what type of pulse?
Normal
A patient is recovering from several hours of orthopedic 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.
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