Chapter 16: Blood Vessels

Multiple Choice

1. Induration, edema, and hyperpigmentation are common associated findings with which of the following?

a. Peripheral arterial disease b. Venous ulcer c. Arterial embolic disease d. Venous thrombus

ANS: B

A venous ulcer also results from chronic venous insufficiency and demonstrates induration edema and hyperpigmentation. Peripheral arterial edema results in ischemia, in which the foot or leg is painful and cold; nonulceration is common as the muscles atrophy. Arterial embolic disease includes occlusion of the small arteries, resulting in blue toe syndrome and splinter hemorrhages in the nail bed. A venous thrombus presents with minimal ankle edema, low-grade fever, tachycardia, and possibly a positive Homan sign.

DIF: Cognitive Level: Applying (Application)

MSC: Physiologic Integrity: Reduction of Risk Potential

OBJ: Nursing process diagnosis

2. The most prominent component of the jugular venous pulse is the: a. a wave. b. c wave. c. v wave. d. x slope.

ANS: A

The a wave is the first and most prominent component of the jugular venous pulse. The a wave represents a brief backflow of blood into the vena cava during right atrial contraction.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment

MSC: Physiologic Integrity: Reduction of Risk Potential

3. During a routine prenatal visit, Ms. T was noted as having dependent edema, varicosities of the legs, and hemorrhoids. She expressed concern about these symptoms. You explain to Ms. T that her enlarged uterus is compressing her pelvic veins and her inferior vena cava. You would further explain that these findings: a. are usual conditions during pregnancy. b. indicate a need for hospitalization. c. indicate the need for amniocentesis. d. suggest that she is having twins.

ANS: A

Explain to the patient that these are usual conditions during pregnancy. Blood in the lower extremities tends to pool in later pregnancy because of the occlusion of the pelvic veins and inferior vena cava from pressure created by the enlarged uterus. This occlusion results in an increase in dependent edema, varicosities of the legs and vulva, and hemorrhoids.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

4. Vascular changes expected in the older adult include: a. loss of vessel elasticity. b. decreased peripheral resistance. c. decreased pulse pressure. d. constriction of the aorta and major bronchi.

ANS: A

With age, the walls of the arteries become calcified and they lose their elasticity and vasomotor tone; therefore, they lose their ability to respond appropriately to changing body needs. Increased peripheral vascular resistance occurs, causing an increase in blood pressure.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential a. Thick, calloused skin b. Ruddy, thin skin c. Warmer temperature of extremity in contrast to other body parts d. Loss of hair over the extremities

5. You are examining Mr. S, a 79-year-old diabetic man complaining of claudication. Which of the following physical findings is consistent with the diagnosis of peripheral arteri al disease?

ANS: D

An individual with peripheral artery disease or claudication will have thin skin with localized pallor and cyanosis, a loss of body warmth in the affected area, and loss of hair over the extremities.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

6. You are performing a physical examination on a 46-year-old male patient. His examination findings include the following: positive peripheral edema, holosystolic murmur in the tricuspid region, and a pulsatile liver. His diagnosis is: a. an aortic aneurysm. b. an arteriovenous fistula. c. tricuspid stenosis. d. tricuspid regurgitation.

ANS: D

An aneurysm is a localized isolation that results in a pulsatile swelling and a thrill or bruit. An arteriovenous fistula is a pathologic communication between an artery and vein resulting in a thrill or bruit and edema or ischemia in the involved extremity. Tricuspid regurgitation results in a holosystolic murmur in the tricuspid region, a pulsatile liver, and peripheral edema.

DIF: Cognitive Level: Analyzing (Analysis) OBJ: Nursing process diagnosis MSC: Physiologic Integrity: Reduction of Risk Potential a. Vasospasm b. Digital ischemia with pain c. Triphasic demarcated skin d. Cold and achy improving with warming

7. A characteristic distinguishing primary Raynaud phenomenon from secondary Raynaud phenomenon includes which of the following?

ANS: B

In primary Raynaud phenomenon, there is triphasic demarcation of the skin white, cyanotic, and reperfused and vasospasm that lasts a minutes to less than an hour, areas of cold, and an achy feeling that improves with rewarming. In secondary Raynaud phenomenon, there is intense pain from digital ischemia.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

8. In children, coarctation of the aorta should be suspected if you detect: a. a delay between the radial and femoral pulses. b. a simultaneous radial and femoral pulse. c. an absent femoral pulse on the left. d. bilateral absence of femoral pulses.

ANS: A

Coarctation of the aorta is a congenital stenosis or narrowing seen most commonl y in the descending aortic arch, near the origin of the left subclavian artery and ligamentum arteriosum. Ordinarily, the radial and femoral pulses are palpated simultaneously. When there is a delay and/or a palpable diminution of amplitude of the femoral pulse, coarctation must be suspected. Differences in blood pressure taken in the arms and legs should confirm the suspicion. Coarctation of the aorta should not be suspected if the radial and femoral pulses are palpated simultaneously, if the femoral pulse on the left is absent, or if there is bilateral absence of femoral pulses.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential a. The major symptom is severe leg pain, especially when walking. b. The affected leg is commonly pale and hairless, and pulses are difficult to palpate. c. Diabetes, peripheral neuropathy, and nutritional deficiencies are causative factors. d. The ulcers are generally located on the tips of toes.

9. Which of the following statements is true regarding the development of venous ulcers in older adults?

ANS: C

Venous ulcers are generally found on the medial or lateral aspects of the lower limbs, most often in older adults. Induration, edema, and hyperpigmentation are common. Heart failure, hypoalbuminemia, peripheral neuropathy, diabetes mellitus, nutritional deficiencies, and arterial disease cause the venous ulcers to develop. The major symptom of venous ulcers is not severe leg pain. In patients with venous ulcers, the affected leg is not commonly pale and hairless, and pulses are not difficult to palpate. Venous ulcers are not generally located on the tips of toes.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

10. When examining arterial pulses the thumb may be used: a. especially if vessels have a tendency to move. b. never for palpating pulses. c. checking the jugular venous pressure. d. during the Allen test.

ANS: A

The thumb may be used, especially if the vessels have a tendency to move when probed by the fingers. The thumb is particularly useful in fixing the brachial and even the femoral pulses. You cannot palpate for jugular venous pressure waves. The Allen test is used to ensure ulnar patency prior to radial artery puncture.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential a. Supine b. Semi-Fowler c. Upright d. Left lateral recumbent

11. To assess a patient s jugular veins, the patient should first be placed in which position?

ANS: A

To assess jugular veins, place the patient in the supine position. This causes engorgement of the jugular veins. Then gradually raise the head of the bed until the pulsations of the jugular vein become visible between the angle of the jaw and the clavicle. Jugular veins cannot be palpated.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

12. Observation of hand veins can facilitate the assessment of: a. mitral valve competency. b. a heart murmur. c. right heart pressure. d. left heart pressure.

ANS: C

Hand veins can be used as an auxiliary manometer of right heart pressure. Assess the hand veins hile the hand is at the patient s side. Then raise the hand until the veins collapse, and use a ruler to measure the vertical distance between the midaxillary line (level of the heart) and the level of the collapsed hand veins.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

13. You are assessing Mr. Z s fluid volume status as a result of heart failure. If our finger depresses a patient s edematous ankle to a depth of 6 mm, ou should record this pitting as: a. 1+. b. 2+. c. 3+. d. 4+.

ANS: C

Pitting edema to 6 mm represents a 3+ rating. This edema is noticeably deep and may last more longer a minute; the dependent extremity looks fuller and swollen. Edema is graded on a scale of mild (1+) through worse (4+).

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

14. A bounding pulse in an infant may be associated with: a. patent ductus arteriosus. b. coarctation of the aorta. c. decreased cardiac output. d. peripheral vaso-occlusion.

ANS: A

A bounding pulse is associated with a large left-to-right shunt produced by a patent ductus arteriosus. A weaker or thinner pulse represents diminished cardiac output or peripheral vasoconstriction. A difference in pulse amplitude between the upper extremities or between the femoral and radial pulses, and absence of the femoral pulse, suggests a coarctation of the aorta.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

15. In infants or small children, a capillary refill time of 4 seconds: a. is normal. b. indicates hypervolemia. c. indicates dehydration or hypovolemic shock. d. indicates renal artery stenosis.

ANS: C

Capillary refill time represents the time it takes the capillary bed to refill after being occluded by pressure to the nail bed for several seconds. Observe the time it takes for the nail to regain its full color, which should be less than 2 seconds for an intact system. The capillary refill time will be longer than 2 seconds during arterial occlusion, hypovolemic shock, hypothermia, and dehydration.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

16. A venous hum heard over the internal jugular vein of a child: a. usually signifies untreatable illness. b. usually has no pathologic significance. c. usually requires surgical intervention. d. must be monitored until the child is grown.

ANS: B

A venous hum is caused by the turbulence of blood flow in the internal jugular veins. It is common in children and usually has no pathologic significance. To detect a venous hum, auscultate over the right supraclavicular space at the medial end of the clav icle and along the anterior border of the sternocleidomastoid muscle. It is louder during diastole.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential a. Immediate emergency surgery is indicated. b. Pedal pulses are not always palpable. c. Unilateral pulses are never normal. d. Venogram studies will be needed.

17. You are palpating bilateral pedal pulses and cannot feel one of the pulses. The feet are equally warm. You find that both great toes are pink, with a capillary refill within 2 seconds. Which of the following statements is correct?

ANS: B

Dorsalis pedis and posterior tibia pulses may be difficult to palpate or may not be palpable in some well persons. The feet are warm and capillary refill is less than 2 seconds; there is adequate circulation to the feet. Immediate emergency surgery is not indicated. Unilateral pulses may be normal. Venogram studies will not be needed.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

Multiple Response

1. When palpating the carotid artery, which of the following is most important? (Select all that apply.)

a. Rotate the patient s head to the side being e amined to rela the sternocleidomastoid.

b. Excessive carotid sinus massage can compromise blood flow to the brain.

c. Excessive carotid sinus massage can cause slowing of the pulse.

d. Palpate both sides simultaneously.

ANS: A, B, C

When palpating the carotid arteries, never palpate both sides simultaneously. Excessive carotid sinus massage can cause slowing of the pulse and a drop in blood pressure and can compromise blood flow to the brain, leading to syncope. If you have difficulty feeling the pulse, rotate the patient s head to the side being e amined to rela the sternocleidomastoid muscle.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential a. Gender b. Alcohol use c. Lower extremity trauma d. Increased body mass e. Hypertension f. Diabetes

2. Which are risk factors for varicose veins? (Select all that apply.)

ANS: A, C, D

Gender (women are four times more likely than men to have varicose veins genetic predisposition), tobacco use, increased body mass, age, and history of lower extremity trauma are all risk factors for varicose veins.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment

MSC: Physiologic Integrity: Reduction of Risk Potential