Nursing Assessment of Lower Extremities

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Questions and Answers

What is one of the factors contributing to Latinos in the U.S. having a higher risk of developing diabetes compared to non-Hispanic Caucasians?

  • Exercise
  • Decreased effectiveness of blood vessels (correct)
  • Annual check ups
  • Balanced diet

Which type of arteries are thicker and dilate less effectively according to the text?

  • Systemic arteries
  • Peripheral arteries (correct)
  • Proximal arteries
  • Coronary arteries

What is a suggested strategy for managing health and wellness mentioned in the text?

  • Lack of exercise
  • Smoking cessation
  • Excessive alcohol consumption
  • Balanced diet (correct)

Which one of these is NOT mentioned as part of a nursing history assessment in the text?

<p>Recent vacation plans (B)</p> Signup and view all the answers

What is one of the reasons for advising the client to void before abdominal assessment, as mentioned in the text?

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

What is one of the signs of skin abnormalities mentioned in the text during a physical assessment?

<p>Tense glistening skin (A)</p> Signup and view all the answers

What might asymmetrical contour in the abdomen indicate, based on the text?

<p>Hernia or tumor (D)</p> Signup and view all the answers

What is the recommended order of assessment for a comprehensive physical examination?

<p>Head to toe (B)</p> Signup and view all the answers

Which of the following is NOT included in the factors to consider during a physical assessment?

<p>Recent vacations (B)</p> Signup and view all the answers

What does a sustained decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure indicate?

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

What does cyanosis refer to in a physical assessment?

<p>Bluish tinge of the lips, ear lobes, or buccal mucosa (D)</p> Signup and view all the answers

Where would you auscultate for a bruit during a physical examination of the cardiovascular system?

<p>Carotid arteries (C)</p> Signup and view all the answers

Which valve area is associated with the 4th and 5th left intercostal space along the mid-clavicular line?

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

When is the closure of the mitral and tricuspid valves (S1) heard best during the cardiac cycle?

<p>In early diastole (C)</p> Signup and view all the answers

"S3" heart sound is most likely to be heard in which group of individuals?

<p>Children and younger adults (A)</p> Signup and view all the answers

What does nonpitting edema feel like?

<p>It feels hard to touch with no indentation when firm pressure is applied. (A)</p> Signup and view all the answers

How is a 3+ pulse intensity described?

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

What does cyanosis and marked edema indicate?

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

What does it indicate if skin is thin, shiny, or waxy shiny with reduced hair and ulceration?

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

In the grading of the intensity of pulses, what does 1+ represent?

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

What does a dusky red color when limb is lowered indicate?

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

What does a capillary refill test help indicate?

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

Which racial/ethnic groups have a higher incidence of hypertension according to the text?

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

What should a nursing history of the cardiovascular and peripheral vascular systems include?

<p>Subjective and objective data (D)</p> Signup and view all the answers

Why is it important to obtain data from observation, auscultation, palpation, and patient history when assessing the cardiovascular system?

<p>To obtain a comprehensive assessment (C)</p> Signup and view all the answers

Which of the following is a key question to ask during a nursing assessment of the cardiovascular system?

<p>How long have you had this symptom(s)? (C)</p> Signup and view all the answers

Why is understanding how symptoms affect a patient's lifestyle important during a cardiovascular assessment?

<p>To determine potential interventions (D)</p> Signup and view all the answers

Which data source is NOT typically included in a nursing history of the cardiovascular system?

<p>Social media activity (B)</p> Signup and view all the answers

How can patient, family, and medical history contribute to the assessment of cardiovascular systems?

<p>By providing valuable context and information (B)</p> Signup and view all the answers

Which question aims to understand the patient's perception about the cause of their cardiovascular symptoms?

<p>What do you think is causing the problem? (D)</p> Signup and view all the answers

What type of data is essential for an effective assessment of the cardiovascular system?

<p>A combination of subjective and objective data (D)</p> Signup and view all the answers

What is the significance of high lactose intolerance among certain ethnic groups?

<p>Slower peristalsis and less frequent bowel movements (A)</p> Signup and view all the answers

Which abdominal finding is indicative of a distended and palpable tense mass?

<p>Bladder not palpable (A)</p> Signup and view all the answers

What is a characteristic symptom of high fiber diets with high quantities of raw fresh foods?

<p>More active gastrocolic and duodenocolic reflexes (B)</p> Signup and view all the answers

Which ethnic groups have a higher incidence of high lactose intolerance?

<p>African Americans and Native Americans (C)</p> Signup and view all the answers

Which sign suggests liver disease when palpating the abdomen?

<p>Liver enlargement, smooth but tender-nodular hard (A)</p> Signup and view all the answers

What does muscle wasting and loss of fibroconnective tissue result in?

<p>Increased adipose tissue (B)</p> Signup and view all the answers

Why is decreased medication absorption associated with certain ethnic groups?

<p>Lowered gastric acid secretion (B)</p> Signup and view all the answers

What is the significance of hyperactive bowel sounds (>35 per minute)?

<p>Suggests increased peristalsis (D)</p> Signup and view all the answers

Flashcards

Peripheral Arteries

Peripheral arteries are generally thicker and less effective at dilation.

Orthostatic Hypotension

A sustained decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure upon standing.

Cyanosis

Bluish tinge of the lips, ear lobes, or buccal mucosa, indicating low oxygen saturation.

Bruit (Carotid)

A whooshing sound auscultated over the carotid arteries, indicating turbulent blood flow.

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Tricuspid Valve Area

Located at the 4th and 5th left intercostal space along the mid-clavicular line.

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S1 Heart Sound

Closure of the mitral and tricuspid valves is best heard in early diastole and creates the S1 sound.

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S3 Heart Sound

Can be a normal finding in children and younger adults. May indicate heart failure in older adults.

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Nonpitting Edema

Feels hard to the touch, with no indentation remaining after applying firm pressure.

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3+ Pulse Intensity

Full/bounding: easily palpable and forceful.

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Venous Insufficiency Signs

Cyanosis and marked edema often indicate impaired venous return and pooling of blood.

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Arterial Insufficiency Signs

Thin, shiny, or waxy skin with reduced hair and possible ulceration indicates reduced blood supply.

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1+ Pulse Intensity

Weak/thready: difficult to palpate, fades in and out, easily obliterated by pressure.

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Dependent Rubor

Dusky red color when the limb is lowered indicates deficient arterial blood supply.

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Capillary Refill Test

Assess arterial blood flow to the extremities, by how quickly color returns to nail beds after blanching.

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Hypertension Risk

African American, Puerto Ricans, Cubans & Latinos have a higher incidence of hypertension

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Cardiovascular Nursing History

Subjective and objective data, including patient history, symptoms, and physical findings, are essential for thorough assessment.

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Comprehensive Cardiovascular Assessment

Observation, auscultation, palpation, and patient history provide a holistic understanding of the patient's cardiovascular health.

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Symptom Timeline

Details the onset, duration, frequency, and progression of the patient's symptoms.

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Lifestyle Impact

Understanding the impact of symptoms on daily activities helps tailor interventions.

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Irrelevant History Data

Social media activity is not typically part of a nursing history.

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Importance of Medical History

Patient, family medical history offers essential insights into potential contributing factors.

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Patient's Perception

Exploring patient's perceptions about the cause of their symptoms guides appropriate care strategies.

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Combined Data

Combining subjective and objective data ensures a thorough and accurate assessment.

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Lactose Intolerance Effects

High lactose intolerance can lead to slower peristalsis and less frequent bowel movements.

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Distended Bladder Sign

Indicates a distended bladder when a tense mass is palpable upon abdominal assessment.

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High Fiber Diet

Eating fibre rich foods can stimulate gastrocolic and duodenocolic reflexes resulting in bowel movements

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High Lactose Ethnic Groups

African Americans and Native Americans are more prone to lactose intolerance.

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Liver Disease Sign

Enlarged, smooth, tender, nodular or hard liver suggests underlying liver issues.

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Muscle Wasting Outcomes

Lead to decreased muscle and fibroconnective tissue, with increased fat tissue.

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Low Gastric Acid Effect

Decreased medication absorption is associated with lowered gastric acid secretion prevalent in certain ethnic groups.

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Hyperactive Bowel Sounds

Hyperactive bowel sounds suggest increased peristalsis which can happen with diarrhea or irritable bowel.

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