Exam (elaborations)
NURS347 Final Health Assmnt.
- Module
- NTFS 2530 Exam 1
- Institution
- NTFS 2530 Exam 1
NURS347 Final Health Assmnt.
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NURS347 Final Health AssmntA 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:
Problems related to arterial insufficiency.
3 multiple choice options
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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:
Raynaud's phenomenon
3 multiple choice options
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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?
Right calf slightly red and swollen a few cm larger than the left calf with all pulses
equal bilaterally.
3 multiple choice options
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?
Earlobe
3 multiple choice options
,How should the nurse document mild, slight pitting edema the ankles of a
pregnant patient?
1+
3 multiple choice options
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A patient has been diagnosed with venous stasis. Which of these findings would
the nurse most likely observe?
Brownish discoloration to the skin of the lower leg
3 multiple choice options
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?
3+
3 multiple choice options
A patient has been diagnosed with venous stasis. Which of these findings would
the nurse most likely observe?
Brownish discoloration to the skin of the lower leg
3 multiple choice options
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:
Consider this finding as normal, and proceed with the peripheral vascular
evaluation.
3 multiple choice options
,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?
Weak
3 multiple choice options
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Claudication is caused by:
arterial insufficiency
3 multiple choice options
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?
Person who has been on bed rest for 4 days
3 multiple choice options
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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?
Examine the patient's lower arm and hand, and check for the presence of
infection or lesions.
3 multiple choice options
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While 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
Impaired tissue perfusion
, The nurse is preparing to assess the dorsalis pedis artery. Where is the correct
location for palpation?
Lateral to the extensor tendon of the great toe
3 multiple choice options
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The nurse is preparing to assess the dorsalis pedis artery. Where is the correct
location for palpation?
Lateral to the extensor tendon of the great toe
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The nurse is evaluating patients for obesity-related diseases by calculating the
waist-to-hip ratios. Which one of these patients would be at increased risk?
29-year-old woman whose waist measures 33 inches and hips measure 36
inches
3 multiple choice options
The nurse is percussing the seventh right intercostal space at the midclavicular
line over the liver. Which sound should the nurse expect to hear?
Dullness
3 multiple choice options
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During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid
wave test occurs with:
Ascites
3 multiple choice options
The nurse is assessing a patient for possible peptic ulcer disease. Which
condition or history often causes this problem?
Frequent use of nonsteroidal antiinflammatory drugs
3 multiple choice options
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