Nursing Assessment: Lower Extremities and Peripheral Pulses
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Questions and Answers

What key methods are utilized for the assessment of cardiovascular and peripheral systems?

  • Blood tests, urine analysis, and ECG
  • Observation, auscultation, and palpation (correct)
  • Radiography, MRI, and CT scan
  • Physical therapy, acupuncture, and massage

    • Which of the following is considered a characteristic associated with the cardiovascular system?

  • Shortness of breath (correct)
  • Digestive issues
  • Vision problems
  • Joint pain

    • In nursing history assessment related to cardiovascular systems, which of the following is NOT typically included in subjective data?

  • Chest pain/discomfort
  • MRI results (correct)
  • Shortness of breath (SOB)
  • Palpitations

    • Which question can help understand the impact of symptoms on a person's lifestyle?

    <p>How does it affect your lifestyle?</p> Signup and view all the answers

    What is a key feature of nursing history assessment for cardiovascular systems?

    <p>Observing peripheral skin changes</p> Signup and view all the answers

    Which question aims to identify triggers for specific symptoms?

    <p>Does any particular incident or episode trigger the symptom?</p> Signup and view all the answers

    In assessing cardiovascular and peripheral vascular systems, what should be considered when obtaining patient data?

    <p>Patient's medical history and family history</p> Signup and view all the answers

    'What do you think is causing the problem?' is a question that aims to:

    <p>Understand the patient's perception of symptoms</p> Signup and view all the answers

    What is the significance of Latinos in the U.S. having three times the risk of developing diabetes compared to non-Hispanic Caucasians?

    <p>Healthcare disparities and access issues</p> Signup and view all the answers

    Why are proximal arteries thinner and dilate, while peripheral arteries are thicker and dilate less effectively?

    <p>Effects of diabetes on arterial elasticity</p> Signup and view all the answers

    What is the purpose of subdividing the abdomen into 4 quadrants during assessment?

    <p>To assist in locating organs and documenting findings</p> Signup and view all the answers

    Why is it advised for the client to void before abdominal assessment?

    <p>To promote comfort during the assessment process</p> Signup and view all the answers

    Which abdominal movement is considered normal during assessment?

    <p>Audible bowel sounds</p> Signup and view all the answers

    What does the presence of purple striae on the skin indicate during a nursing assessment?

    <p>Possible Cushing's syndrome</p> Signup and view all the answers

    In a nursing history assessment, what is indicated by past abdominal history, medications, alcohol, and smoking information?

    <p>Relevance to assessing nutritional status</p> Signup and view all the answers

    Why is inspecting oral mucosa part of a nursing assessment?

    <p>To detect signs of possible malnutrition or dehydration</p> Signup and view all the answers

    What does a 3+ grading signify in the intensity/strength of pulses?

    <p>Full/bounding</p> Signup and view all the answers

    Which condition is indicated by cyanosis and marked edema in peripheral perfusion assessment?

    <p>Venous insufficiency</p> Signup and view all the answers

    What is the significance of palpation tenderness and swelling of one calf or leg in peripheral veins assessment?

    <p>Venous insufficiency</p> Signup and view all the answers

    How is nonpitting edema distinguished in peripheral perfusion assessment?

    <p>Feels hard to touch with no indentation when pressure is applied</p> Signup and view all the answers

    What does a 2+ grading signify in the intensity/strength of pulses?

    <p>Normal</p> Signup and view all the answers

    In the capillary refill test, what does it indicate if the nail returns to normal color in more than 3 seconds?

    <p>Inadequate blood supply</p> Signup and view all the answers

    What does a 1+ grading signify in pitting edema assessment?

    <p>(2mm) mild pitting, slight indentation</p> Signup and view all the answers

    Which population group has a higher incidence of hypertension compared to Caucasians?

    <p>African American, Puerto Ricans, Cubans &amp; Latinos</p> Signup and view all the answers

    What is the expected bowel sound rate indicating hyperactivity that the healthcare provider should listen for during auscultation?

    <p>More than 35 sounds per minute</p> Signup and view all the answers

    Which group has a high incidence of lactose intolerance according to the text?

    <p>African Americans, Native Americans, Asians, and Mediterranean groups</p> Signup and view all the answers

    What is the effect of decreased salivation on digestion, as mentioned in the text?

    <p>Decreased gastric acid secretion</p> Signup and view all the answers

    Which reflexes are initiated by food entrance into the stomach and duodenum, facilitating bowel elimination?

    <p>Gastrocolic and duodenocolic reflexes</p> Signup and view all the answers

    What is a characteristic symptom associated with a distended and palpable tense mass in the abdomen?

    <p>Urine retention</p> Signup and view all the answers

    What does a smooth but tendernodular hard liver enlargement suggest during palpation?

    <p>Liver disease</p> Signup and view all the answers

    What is the recommended order of assessment during a physical examination?

    <p>Cephalocaudal</p> Signup and view all the answers

    Which condition may be indicated by the presence of a bruit when assessing the carotid arteries?

    <p>Atherosclerosis</p> Signup and view all the answers

    What could a sustained decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure when moving from lying to standing indicate?

    <p>Orthostatic hypotension</p> Signup and view all the answers

    When is the second heart sound (S2) heard loudest?

    <p>At the base with the diaphragm of the stethoscope</p> Signup and view all the answers

    Which valve is best auscultated at the 5th left intercostal space at the midclavicular line?

    <p>Mitral valve</p> Signup and view all the answers

    What may an S3 heart sound indicate?

    <p>Mitral valve regurgitation</p> Signup and view all the answers

    Why is it important to assess for jugular vein distension (JVD) when examining a patient?

    <p>To evaluate heart function and fluid status</p> Signup and view all the answers

    What is assessed by palpating the carotid arteries for a thrill?

    <p>Vascular heart murmur</p> Signup and view all the answers

    What should a healthcare provider consider when assessing the cardiovascular and peripheral vascular systems?

    <p>Incorporating patient, family, and medical history</p> Signup and view all the answers

    Which method is essential for the assessment of cardiovascular and peripheral systems?

    <p>Listening (auscultation)</p> Signup and view all the answers

    What is an important characteristic associated with the cardiovascular system?

    <p>Highly rhythmic beating</p> Signup and view all the answers

    Which question is useful in understanding the impact of symptoms on a person's lifestyle?

    <p>How does it affect your lifestyle?</p> Signup and view all the answers

    Why is obtaining past medical history important in the nursing history assessment of cardiovascular systems?

    <p>Provides crucial insights into a person's health status</p> Signup and view all the answers

    Which of the following is true regarding cultural variations related to cardiovascular and peripheral systems?

    <p>Cultural variations must be considered in care delivery</p> Signup and view all the answers

    'How far can you walk?' is a significant question in assessing which system?

    <p>'Peripheral vascular system'</p> Signup and view all the answers

    What does a 0 grading signify in the intensity/strength of pulses?

    <p>Absent pulse</p> Signup and view all the answers

    What does nonpitting edema feel like when touched?

    <p>Hard to touch with no indentation</p> Signup and view all the answers

    Which population group has a higher incidence of hypertension compared to Caucasians?

    <p>Mexican Americans</p> Signup and view all the answers

    What is indicated by cyanosis and marked edema in peripheral perfusion assessment?

    <p>Venous insufficiency</p> Signup and view all the answers

    What does a 4+ grading signify in pitting edema assessment?

    <p>'Very deep pitting' with long-lasting indentation</p> Signup and view all the answers

    What is the significance of Latinos in the U.S. having a higher risk of developing diabetes?

    <p>Genetic predisposition</p> Signup and view all the answers

    What is indicated by a very distended and palpable tense mass in the abdomen?

    <p>'Ascites'</p> Signup and view all the answers

    'How quickly should nail color return to normal in the capillary refill test for normal perfusion?'

    <p>'Within 5 seconds'</p> Signup and view all the answers

    What is a potential indicator of high lactose intolerance among certain ethnic groups as mentioned in the text?

    <p>Decreased gastric acid secretion</p> Signup and view all the answers

    Which characteristic is associated with a rounded abdomen due to increased adipose tissue and decreased muscle tone?

    <p>Higher pain threshold</p> Signup and view all the answers

    What is the significance of inspecting the oral mucosa during a nursing assessment?

    <p>To evaluate the client's nutritional intake</p> Signup and view all the answers

    Why is it important for a healthcare provider to subdivide the abdomen into 4 quadrants during assessment?

    <p>To locate organs and aid in documentation</p> Signup and view all the answers

    Which symptom may be associated with a smooth but tendernodular hard liver enlargement during palpation?

    <p>Distention and asymmetry</p> Signup and view all the answers

    How does the presence of purple striae on the skin impact a nursing assessment?

    <p>Implies nutritional deficiencies</p> Signup and view all the answers

    Why is it recommended to advise the client to void before an abdominal assessment?

    <p>To promote comfort during assessment</p> Signup and view all the answers

    What does an asymmetric contour in the abdomen suggest during a nursing assessment?

    <p>Presence of hernia or tumor</p> Signup and view all the answers

    How does inspecting for tense glistening skin contribute to abdominal assessment?

    <p>Suggests distention and asymmetry</p> Signup and view all the answers

    What is the purpose of starting the assessment from cephalocaudal (head to toe) order?

    <p>To ensure a systematic approach and not miss any important findings</p> Signup and view all the answers

    What is the significance of auscultating for a bruit when assessing carotid arteries?

    <p>To identify abnormal sounds indicating potential arterial blockages</p> Signup and view all the answers

    What does it indicate when there is a sustained decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure when moving from lying to standing?

    <p>Orthostatic hypotension</p> Signup and view all the answers

    Why is it recommended to examine the patient in a warm and quiet place at a specific angle?

    <p>To reduce distractions and improve focus during the examination</p> Signup and view all the answers

    What is the expected significance of the second heart sound (S2) heard loudest at the base of the heart?

    <p>Shows normal cardiac function</p> Signup and view all the answers

    'What does a displaced Point of Maximal Impulse (PMI) suggest during a cardiac examination?'

    <p>Valvular disorders</p> Signup and view all the answers

    'What happens when a pulsation is present except for the apical impulse?'

    <p>Suggests normal cardiac function</p> Signup and view all the answers

    'What is typically indicated by pulsations being absent except for the apical impulse?'

    <p>Normal finding in young patients and adults with thin chest walls</p> Signup and view all the answers

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