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? (A)</p> Signup and view all the answers

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

<p>Observing peripheral skin changes (C)</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? (B)</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 (D)</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 (D)</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 (C)</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 (B)</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 (A)</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 (B)</p> Signup and view all the answers

Which abdominal movement is considered normal during assessment?

<p>Audible bowel sounds (B)</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 (D)</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 (A)</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 (A)</p> Signup and view all the answers

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

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

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

<p>Venous insufficiency (D)</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 (C)</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 (C)</p> Signup and view all the answers

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

<p>Normal (D)</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 (C)</p> Signup and view all the answers

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

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

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

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

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

<p>Cephalocaudal (D)</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 (E)</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 (D)</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 (C)</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 (D)</p> Signup and view all the answers

What may an S3 heart sound indicate?

<p>Mitral valve regurgitation (C)</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 (B)</p> Signup and view all the answers

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

<p>Vascular heart murmur (A)</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 (C)</p> Signup and view all the answers

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

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

What is an important characteristic associated with the cardiovascular system?

<p>Highly rhythmic beating (D)</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? (B)</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 (D)</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 (C)</p> Signup and view all the answers

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

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

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

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

What does nonpitting edema feel like when touched?

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

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

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

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

<p>Venous insufficiency (B)</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 (B)</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 (A)</p> Signup and view all the answers

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

<p>'Ascites' (B)</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' (C)</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 (C)</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 (C)</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 (C)</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 (B)</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 (D)</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 (C)</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 (D)</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 (C)</p> Signup and view all the answers

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

<p>Suggests distention and asymmetry (A)</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 (B)</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 (B)</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 (D)</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 (C)</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 (C)</p> Signup and view all the answers

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

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

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

<p>Suggests normal cardiac function (C)</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 (D)</p> Signup and view all the answers

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