Nursing Assessment: Lower Extremities and Peripheral Pulses

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

Observation, auscultation, and palpation

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

Shortness of breath

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

MRI results

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

How does it affect your lifestyle?

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

Observing peripheral skin changes

Which question aims to identify triggers for specific symptoms?

Does any particular incident or episode trigger the symptom?

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

Patient's medical history and family history

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

Understand the patient's perception of symptoms

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

Healthcare disparities and access issues

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

Effects of diabetes on arterial elasticity

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

To assist in locating organs and documenting findings

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

To promote comfort during the assessment process

Which abdominal movement is considered normal during assessment?

Audible bowel sounds

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

Possible Cushing's syndrome

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

Relevance to assessing nutritional status

Why is inspecting oral mucosa part of a nursing assessment?

To detect signs of possible malnutrition or dehydration

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

Full/bounding

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

Venous insufficiency

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

Venous insufficiency

How is nonpitting edema distinguished in peripheral perfusion assessment?

Feels hard to touch with no indentation when pressure is applied

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

Normal

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

Inadequate blood supply

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

(2mm) mild pitting, slight indentation

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

African American, Puerto Ricans, Cubans & Latinos

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

More than 35 sounds per minute

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

African Americans, Native Americans, Asians, and Mediterranean groups

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

Decreased gastric acid secretion

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

Gastrocolic and duodenocolic reflexes

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

Urine retention

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

Liver disease

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

Cephalocaudal

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

Atherosclerosis

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?

Orthostatic hypotension

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

At the base with the diaphragm of the stethoscope

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

Mitral valve

What may an S3 heart sound indicate?

Mitral valve regurgitation

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

To evaluate heart function and fluid status

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

Vascular heart murmur

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

Incorporating patient, family, and medical history

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

Listening (auscultation)

What is an important characteristic associated with the cardiovascular system?

Highly rhythmic beating

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

How does it affect your lifestyle?

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

Provides crucial insights into a person's health status

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

Cultural variations must be considered in care delivery

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

'Peripheral vascular system'

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

Absent pulse

What does nonpitting edema feel like when touched?

Hard to touch with no indentation

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

Mexican Americans

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

Venous insufficiency

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

'Very deep pitting' with long-lasting indentation

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

Genetic predisposition

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

'Ascites'

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

'Within 5 seconds'

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

Decreased gastric acid secretion

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

Higher pain threshold

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

To evaluate the client's nutritional intake

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

To locate organs and aid in documentation

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

Distention and asymmetry

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

Implies nutritional deficiencies

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

To promote comfort during assessment

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

Presence of hernia or tumor

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

Suggests distention and asymmetry

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

To ensure a systematic approach and not miss any important findings

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

To identify abnormal sounds indicating potential arterial blockages

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?

Orthostatic hypotension

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

To reduce distractions and improve focus during the examination

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

Shows normal cardiac function

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

Valvular disorders

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

Suggests normal cardiac function

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

Normal finding in young patients and adults with thin chest walls

Test your knowledge on assessing lower extremities and peripheral pulses in nursing. Topics include inspecting lower limbs, checking skin temperature, palpating peripheral pulses, assessing range of motion and muscle strength, and grading pulse intensity. Ideal for nursing students and healthcare professionals.

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