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) OBJ: Nursing process diagnosis
MSC: Physiologic Integrity: Reduction of Risk Potential
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)
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