Exam (elaborations)
NURS347 - Final Exam (1).
- Module
- NTFS 2530 Exam 1
- Institution
- NTFS 2530 Exam 1
NURS347 - Final Exam (1).
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NURS347 - Final ExamWhile performing an admission assessment for a client, the nurse notes that the
client has varicose veins with ulcerations and lower extremity edema with a
report of a feeling of heaviness. Which of the following nursing diagnoses should
the nurse identify as being the priority in the client's care?
a. Impaired skin integrity
b. Alteration in body image
c. Alteration in activity tolerance
d. Impaired tissue perfusion - CORRECT ANSWER-d. Impaired tissue perfusion
S.E. is a 30 year old Caucasian male with no significant past medical history and
family history is unremarkable. He had a recent basketball injury resulting in a
torn Achilles tendon 3 weeks ago and a non-weight bearing cast was placed. He
is complaining of right calf pain. Which of the following is indicative of deep vein
thrombosis?
a. Left leg tan with pale cool toes
b. Dull throbbing right leg pain with cold pale toes
c. Intermittent sharp stabbing right ankle pain without edema
d. Right calf slightly red and swollen a few cm larger than the left calf with all
pulses equal bilaterally. - CORRECT ANSWER-d. Right calf slightly red and
swollen a few cm larger than the left calf with all pulses equal bilaterally.
A patient has been diagnosed with venous stasis. Which of these findings would
the nurse most likely observe?
a. Brownish discoloration to the skin of the lower leg
b. Pallor of the toes and cyanosis of the nail beds
c. Thin, shiny, atrophic skin
d. Unilateral cool foot - CORRECT ANSWER-a. Brownish discoloration to the
skin of the lower leg
When performing an assessment of a patient, the nurse notices the presence of
an enlarged right epitrochlear lymph node. What should the nurse do next?
a. Ask additional health history questions regarding any recent ear infections or
sore throats
b. Assess the patient's abdomen, and notice any tenderness
c. Carefully assess the cervical lymph nodes, and check for any enlargement
,d. Examine the patient's lower arm and hand, and check for the presence of
infection or lesions - CORRECT ANSWER-d. Examine the patient's lower arm
and hand, and check for the presence of infection or lesions
A patient complains of leg pain that wakes him at night. He states that he "has
been having problems" with his legs. He has pain in his legs when they are
elevated that disappears when he dangles them. He recently noticed "a sore" on
the inner aspect of the right ankle. On the basis of this health history information,
the nurse interprets that the patient is most likely experiencing:
a. Problems related to venous insufficiency
b. Pain related to lymphatic abnormalities
c. Pain related to musculoskeletal abnormalities
d. Problems related to arterial insufficiency - CORRECT ANSWER-d. Problems
related to arterial insufficiency
During an assessment, a patient tells the nurse that her fingers often change
color when she goes out in cold weather. She describes these episodes as her
fingers first turning white, then blue, then red with a burning, throbbing pain. The
nurse suspects that she is experiencing:
a. Chronic arterial insufficiency
b. Raynaud's phenomenon
c. Lymphedema
d. Deep-vein thrombosis - CORRECT ANSWER-b. Raynaud's phenomenon
A nurse is preparing to measure a client's level of oxygen saturation and
observes edema of both hands and thickened toe nails. The nurse should apply
the pulse oximeter probe to which of the following locations?
a. Toe
b. Skin fold
c. Earlobe
d. Finger - CORRECT ANSWER-c. Earlobe
When performing a peripheral vascular assessment on a patient, the nurse is
unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill
time is normal. Next, the nurse should:
a. Ask the patient if he or she has experienced any unusual cramping or tingling
in the arm
,b. Consider this finding as normal, and proceed with the peripheral vascular
evaluation
c. Check for the presence of claudication
d. Refer the individual for further evaluation - CORRECT ANSWER-b. Consider
this finding as normal, and proceed with the peripheral vascular evaluation
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct
location for palpation?
a. Over the lateral malleolus
b. In the groove behind the medial malleolus
c. Behind the knee
d. Lateral to the extensor tendon of the great toe - CORRECT ANSWER-d.
Lateral to the extensor tendon of the great toe
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm
(0.25 in) at the point of pressure. Which of the following notations should the
nurse use to document the severity of the client's edema?
a. 1+
b. 2+
c. 3+
d. 4+ - CORRECT ANSWER-c. 3+
How should the nurse document mild, slight pitting edema the ankles of a
pregnant patient?
a. 2+
b. 4+
c. 1+
d. 3+ - CORRECT ANSWER-c. 1+
Claudication is caused by:
a. Venous insufficiency
b. arterial insufficiency
c. stasis ulcerations
d. Varicose veins - CORRECT ANSWER-b. arterial insufficiency
, The nurse is reviewing an assessment of a patient's peripheral pulses and
notices that the documentation states that the radial pulses are "1+." The nurse
recognizes that this reading indicates what type of pulse?
a. Normal
b. Absent
c. Weak
d. Bounding - CORRECT ANSWER-c. weak
The nurse is reviewing the risk factors for venous disease. Which of these
situations best describes a person at highest risk for the development of venous
disease?
a. Women in her second month of pregnancy
b. Person with a 30-year, 1 pack a day smoking habit
c. Older adult taking anticoagulant medication
d. Person who has been on bed rest for 4 days - CORRECT ANSWER-d. Person
who has been on bed rest for 4 days
The nurse is reviewing an assessment of a patient's peripheral pulses and
notices that the documentation states that the radial pulses are "1+". The nurse
recognizes that this reading indicates what type of pulse?
a. Normal
b. Weak
c. Absent
d. Bounding - CORRECT ANSWER-b. Weak
A patient's abdomen is bulging and stretched in appearance. The nurse should
describe this finding as:
a. Obese.
b. Herniated.
c. Scaphoid.
d. protuberant. - CORRECT ANSWER-d. protuberant
The nurse is assessing the forms of support an older patient has before she is
discharged. Which of these examples is an informal source of support?
a. Local senior center
b. Patient's Medicare check
c. Meals on Wheels meal delivery service
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