NR-304 Health Assessment II - Set 1 - Part 2

Correct Answer: Ischemic rest pain with a threatened limb

Pain occurring without exercise, worse lying flat and relieved by dependency is ischemic rest pain, a separate and more advanced stage than claudication. Resting demand now exceeds supply and the limb is threatened. Option a is incorrect because claudication is exertional and settles within minutes of stopping; pain that appears while the client is lying still in bed is not claudication of any severity. Option b is incorrect because venous ulcers sit above the medial malleolus, ache with standing and feel better with the leg raised, whereas raising this client's foot is precisely what makes the pain worse. Option c is incorrect because ordinary night cramps grip the calf muscle and ease with stretching or walking, while this pain sits in the toes and responds specifically to dependency.

Correct Answer: Below the knee in the tibial vessels

A pulse is present above an occlusion and absent below it, so strong femoral and popliteal pulses with absent pedal pulses place the lesion in the tibial vessels distal to the knee. Option a is incorrect because aortoiliac disease costs the femoral pulse and everything below it, and it produces buttock, hip and thigh claudication rather than the isolated pedal loss described here. Option c is incorrect because a groin lesion would abolish the popliteal pulse as well, since the popliteal artery is simply the femoral artery renamed where it courses behind the knee. Option d is incorrect because deep vein obstruction impairs drainage and shows up as swelling, warmth and a heavy ache, while pulses stay palpable; missing pulses and a cool foot point to arterial inflow.

Correct Answer: The narrowing may have progressed toward complete occlusion

A bruit softens and disappears as flow falls through a critically narrow lumen, and a completely occluded artery is silent. With symptoms worsening, the disappearance suggests progression rather than improvement and needs urgent evaluation. Option a is incorrect because new neurologic symptoms contradict any claim of recovery; loudness never grades severity, and a quiet artery in a client who is getting worse is an alarming sign. Option b is incorrect because silence can mean either an open vessel or one carrying almost no flow at all, so the absence of turbulence cannot by itself establish that the lumen is clear. Option d is incorrect because technique is worth rechecking at the jaw angle, midcervical area and base of the neck, yet blaming the equipment would delay acting on transient ischemic symptoms.

Correct Answer: It matures T lymphocytes and atrophies after puberty

The thymus lies in the superior mediastinum behind the sternum. It is large in the fetus and young child because it matures T lymphocytes, and it atrophies after puberty once that work is largely done. Option a is incorrect because red cell storage is a function of the spleen, which holds a reserve of red cells and platelets in the left upper quadrant. The thymus stores no blood cells at all. Option c is incorrect because filtering lymph is the job of the lymph nodes strung along the lymphatic vessels. Lymph from the lower body travels up the thoracic duct and bypasses the thymus entirely. Option d is incorrect because antibody production belongs to B lymphocytes, which originate in bone marrow and mature in lymphoid tissue, and to the white pulp of the spleen. Lifelong antibody output is not a thymic role.

Correct Answer: A client whose pedal pulse is newly absent

A pulse that was palpable and is now gone signals acute arterial occlusion until proven otherwise, and ischemic muscle and nerve tolerate only hours. The other three findings are chronic and can safely wait. Option a is incorrect because bilateral pitting edema points to a generalized cause and calls for an unhurried look at the neck veins. Nothing about it threatens the limb within the next hour. Option b is incorrect because a weeping medial ankle ulcer is the chronic picture of venous disease, which develops over months. It needs compression and elevation on a planned schedule, not immediate bedside evaluation. Option c is incorrect because hemosiderin staining is a permanent record of venous hypertension that has been present for a long time. Staining tells the nurse about the past, not about perfusion failing right now.

Correct Answer: Venous, from sustained ambulatory venous hypertension

Every discriminator here is venous. A medial malleolar site, irregular edges, heavy exudate, brown hemosiderin staining, a warm limb and a normal 2+ pulse together mean blood is arriving but not draining. Option b is incorrect because an arterial ulcer sits on the toes, metatarsal heads, heel or lateral malleolus, has round punched out edges, and lies in a cold limb whose pulses are weak or absent. Option c is incorrect because lymphedema produces brawny nonpitting swelling that involves the dorsum of the foot and the toes, with a positive Stemmer sign. It rarely ulcerates unless infection intervenes, and it does not stain skin brown. Option d is incorrect because a neuropathic ulcer forms over repetitive stress points such as the plantar metatarsal heads and clawed toe tips in a client who cannot feel it developing. Location and sensation both point elsewhere here.

Correct Answer: I let my legs hang down when they ache.

Arterial pain is relieved by dependency, because gravity adds the perfusion pressure a narrowed artery cannot supply. Elevation removes that help, which is why the arterial instruction is the reverse of the venous one. Option a is incorrect because raising the legs above the heart is the venous instruction and it worsens ischemic pain. In a limb with absent pedal pulses elevation produces pallor rather than relief. Option c is incorrect because crossing the legs compresses vessels in a limb whose inflow is already marginal. Warmth should come from socks and blankets, never from pressure, a heating pad or a hot water bottle. Option d is incorrect because external compression squeezes an artery that is barely delivering blood and can convert claudication into critical ischemia. Compression belongs to venous care and is avoided in significant arterial disease.

Correct Answer: "Stopping smoking is the most powerful change you can make."

Cigarette smoking is the strongest modifiable risk factor for peripheral arterial disease, raising risk roughly fourfold. Tobacco constricts arteries, increases coagulability, injures endothelium and promotes inflammation, so cessation is the first and largest intervention. Option b is incorrect because lipid lowering belongs to risk factor control, which the course ranks below smoking cessation and supervised exercise; statin therapy helps the disease process but does not lead the teaching plan. Option c is incorrect because hypertension sits third on the ranked risk factor list, behind smoking and diabetes; blood pressure control is worth pursuing yet it is not the change with the greatest effect. Option d is incorrect because obesity and a sedentary pattern rank near the bottom of the risk factor list, and weight loss alone leaves the four tobacco mechanisms damaging the arteries untouched.

Correct Answer: Both systems, so compression must not be started yet

The ulcer and staining are venous while the trophic changes and lost pulse are arterial, so both are present. Coexisting arterial disease is exactly what makes compression unsafe until the arterial supply is assessed. Option a is incorrect because a purely venous limb is warm with a normal palpable pulse and hair still present on the foot. The missing pulse and hairless toes cannot be explained by drainage failure. Option b is incorrect because arterial disease produces a dry punched out ulcer on the toes, heel or lateral malleolus and leaves the limb without edema. Brown staining and a weeping medial ulcer are venous signatures. Option c is incorrect because aging may make pedal pulses harder to find, yet it never produces an open ulcer or hemosiderin staining. New, asymmetric findings are never attributed to age alone.

Correct Answer: The finding suggests kidney inflammation

Indirect fist percussion over the costovertebral angle produces vibration rather than sound. A normal person feels only a thud, so sharp pain points to inflammation of the kidney, as in pyelonephritis, and the provider is notified. Option a is incorrect because a dull painless thud is what the nurse expects, and this client had the opposite response. Pain converts the maneuver from a negative screen into a positive one requiring report. Option b is incorrect because in this course the letters stand for costovertebral angle and never for cerebrovascular accident. The maneuver examines the kidney bed, and no part of it evaluates cerebral circulation. Option d is incorrect because the liver lies anteriorly under the right ribs and is outlined by direct percussion of the chest and abdomen. Striking the posterior flank reaches the kidney, not hepatic tissue.

Correct Answer: Elicit the reflexes so the record is true

A finding that was never obtained cannot be charted, whatever its likely value. The correct remedy is to perform the missing maneuver and then document the actual result, which makes the record both complete and truthful. Option a is incorrect because the probability that a result would have been normal is not evidence that it was normal. Recording an assessment never performed is falsification, and the entry's plausibility does not soften that. Option b is incorrect because reflexes are testable in this client, so the phrase misrepresents why the data are missing. That wording is for a maneuver that could not apply, not one the student skipped. Option c is incorrect because a blank proves nothing, while a recorded negative proves the nurse looked. Skipping the row hides the gap instead of closing it, and the reflexes still need to be elicited.

Correct Answer: Pitting edema graded at 3+

Depth alone never settles the grade. At 3+ the pit is deep, the indentation remains for a short time, and the leg looks swollen; at 4+ the indentation lasts a long time and the limb is grossly distorted. Option a is incorrect because 1+ describes mild pitting with only a slight indentation and no perceptible swelling of the leg. This client has a deep pit and a visibly swollen limb, which places the grade much higher. Option c is incorrect because 4+ requires an indentation that lasts a long time in a leg that is grossly swollen and distorted. An indentation that remains only briefly falls one grade below that description. Option d is incorrect because 2+ is moderate pitting whose indentation subsides rapidly, and the limb still does not look swollen at that grade. Visible swelling of the leg itself enters the scale at the next step up.

Correct Answer: Inspect the neck veins for distention

Bilateral pitting edema points to a generalized cause, so the neck veins are examined next. Distended jugulars implicate heart disease or pulmonary hypertension, while flat jugulars point toward liver disease, nephrosis or a medication effect. Option b is incorrect because calf measurement answers a question about asymmetry, and this client already has legs of equal size. Serial measurement is useful for tracking a swollen limb but does not narrow a systemic differential. Option c is incorrect because the Stemmer sign identifies lymphedema, which is brawny and non-pitting and usually involves one limb. Soft pitting swelling of both ankles is not the lymphatic pattern, so the sign would add nothing here. Option d is incorrect because inguinal nodes drain the leg, genitalia and lower abdominal wall and are examined when infection or malignancy is suspected in those territories. Nothing in this presentation suggests a local drainage problem.

Correct Answer: Hold the compression and report the findings

Cool hairless shiny feet with absent pulses indicate arterial insufficiency, an absolute contraindication to compression. Squeezing a limb whose inflow is already marginal can worsen ischemia, so the nurse withholds compression and reports the findings to the provider. Option a is incorrect because an hour of compression on an ischemic limb can convert claudication into critical ischemia. Reassessment does not make an unsafe intervention safe, and the damage may already be done by then. Option b is incorrect because choosing a pressure band is a prescriber decision that follows an ankle brachial index, not a nursing judgment made at the bedside. The nurse has no authority to substitute a different garment. Option d is incorrect because elevation does not restore arterial inflow, and raising an ischemic leg above the heart can actually reduce perfusion further. The contraindication to compression remains whatever position the limb is placed in.

Correct Answer: The dorsal surface of the hand

Skin over the back of the hand is thin, so it equilibrates quickly with the client's surface and registers small temperature differences. This course teaches the dorsum for temperature and compares one limb against the other. Option b is incorrect because finger pads carry the highest density of tactile receptors and are reserved for fine discrimination such as texture, moisture, pulsation and the size and mobility of a lump. Option c is incorrect because the bony ulnar edge transmits vibration efficiently to deep receptors, which makes it the choice for thrills and tactile fremitus rather than for judging how warm a limb feels. Option d is incorrect because opposing the fingers and thumb lets the examiner feel a structure from two sides, which suits position, shape and consistency of an organ or mass, not surface warmth.

Correct Answer: A possible aortic aneurysm needing evaluation

A prominent lateral pulsation in the abdomen suggests aortic aneurysm, in which atherosclerosis weakens the media and arterial pressure balloons the wall. Smoking is the strongest predictor of prevalence, growth and rupture. Option a is incorrect because the aorta is normally felt in the midline, not off to one side, and a laterally prominent pulsation in a man with a long smoking history calls for imaging. Option b is incorrect because a full stomach or bowel gas obscures deep palpation rather than transmitting a visible pulsation, and dismissing the finding as referred would miss a lesion that can rupture. Option d is incorrect because a bruit is a blowing sound heard with a stethoscope over a partially narrowed vessel, not something seen or felt as a pulsation during inspection and palpation.

Correct Answer: Notify the provider of the findings immediately

A new loss of a previously palpable pulse in a limb that is painful, pale and cold is acute arterial occlusion until proven otherwise. The nurse cannot correct it, so immediate notification drives urgent revascularization. Option a is incorrect because elevation subtracts hydrostatic pressure from an already failing arterial supply; an acutely ischemic limb is kept at or below heart level, and elevation belongs to venous congestion instead. Option c is incorrect because heat raises the metabolic demand of tissue that already cannot meet its needs, and an anesthetic limb cannot report a burn, so warming devices are withheld in acute limb ischemia. Option d is incorrect because rubbing or massaging the limb risks dislodging thrombus and sending it further downstream, and it delays the one intervention that matters, which is getting a vascular clinician to the bedside.

Correct Answer: Measure and record height, weight and vital signs

Height, weight and routine vital signs are standardized measurements with predictable outcomes and are within the scope of trained assistive personnel. The nurse keeps the history, the physical examination and the interpretation of every finding. Option a is incorrect because auscultation is a physical examination technique requiring the nurse to judge pitch, frequency and character. Assistive personnel are not prepared to decide whether what they hear is normal or ominous. Option b is incorrect because the admission history is the nurse's own data collection, and the answers shape every later decision. Handing it off would also lose the follow-up questions that only a clinician thinks to ask. Option c is incorrect because assigning a grade to a pulse is an act of clinical judgment, not a measurement. Deciding between a weak vessel and a normal one belongs to the licensed examiner.

Correct Answer: A palmar blush with normal color returning

Adequate collateral flow through the ulnar artery is shown by a palmar blush, the return of the hand to its normal color, which the course times at about two to five seconds. Option a is incorrect because pallor that persists after the ulnar artery is released means the ulnar supply cannot perfuse the hand alone, and radial cannulation must be avoided until adequate flow is demonstrated. Option b is incorrect because a sluggish, drawn out return of color is the abnormal result of this test and signals occlusion of collateral arterial flow rather than the redundancy the palmar arches normally provide. Option d is incorrect because the test watches the color of the palm, not the strength of any pulse; radial pulse amplitude says nothing about whether the ulnar artery alone can supply the whole hand.

Correct Answer: Three plus pitting edema

This course anchors three plus to deep pitting in which the indentation remains and the leg looks swollen. Overall limb appearance only enters the scale at three plus, which is what separates it from two plus. Option a is incorrect because mild pitting at that grade leaves only a slight indentation with no perceptible swelling of the leg. A limb that visibly looks swollen has already moved past the lowest grade. Option b is incorrect because moderate pitting rebounds rapidly and the leg still appears normal in size. Here the pit stayed put, so the rebound description alone rules this grade out before appearance is considered. Option c is incorrect because the top grade requires very deep pitting whose indentation lasts a long time, with a limb described as grossly swollen and distorted. Nothing in this finding reaches that severity.