Peripheral Vascular Detective
A patient reports calf pain after walking one block that is relieved by rest. What condition should the nurse suspect first?
What is peripheral arterial disease (PAD)?
While assessing the abdomen, which technique should the nurse perform first?
What is auscultation?
An older adult reports constipation. Which factor should the nurse assess first?
What is fluid intake?
A patient follows commands but frequently falls asleep during the interview. How should the nurse describe the level of consciousness?
What is lethargic?
A smoker with diabetes reports intermittent leg pain while walking. Which risk factor combination places the patient at highest risk for PAD?
What is diabetes plus smoking?
A 72-year-old client with diabetes reports calf pain while walking, has diminished pedal pulses, delayed capillary refill, and a nonhealing toe ulcer. Which body system findings should the nurse integrate to determine the highest priority concern?
What is impaired arterial perfusion/peripheral arterial disease causing compromised tissue oxygenation?
A patient has cool, pale feet and absent dorsalis pedis pulses bilaterally. What should the nurse do next?
What is compare additional lower extremity pulses and assess circulation/perfusion?
A patient reports abdominal pain. What additional assessment question would provide the most useful subjective information?
What are questions about location, onset, duration, and characteristics of the pain?
A patient presents with abdominal distention. What are the Five Fs that may explain the finding?
What are flatus, fetus, feces, fluid, and fat?
A patient understands questions but struggles to produce words. Which neurological finding is present?
What is Broca's aphasia?
A nurse identifies a carotid bruit during assessment. What is the most appropriate interpretation?
What is turbulent blood flow requiring further evaluation?
A 67-year-old client with a history of smoking reports calf pain that occurs while walking and is relieved by rest. Assessment reveals diminished pedal pulses and cool skin on the affected leg. What condition should the nurse suspect?
What is Peripheral Arterial Disease (PAD)? The combination of intermittent claudication, diminished pulses, and cool extremities indicates impaired arterial blood flow to the lower extremities.
Before obtaining an arterial blood gas from a radial artery, which assessment should the nurse perform?
What is the Allen test?
A patient presents with lower extremity edema. Which health history question best helps identify a vascular cause?
What is asking when the swelling occurs and whether it improves with elevation or rest?
A patient reports black, tarry stools. What should the nurse suspect?
What is gastrointestinal bleeding?
A nurse asks a patient to perform the Romberg test. Which function is being assessed?
What is balance and cerebellar function?
An older adult develops acute confusion during a urinary tract infection. Which age-related neurological consideration applies?
What is delirium may occur before fever in older adults?
A 76-year-old client is brought to the emergency department by family members who report sudden confusion and difficulty finding words. The client is alert, follows commands, and has equal grip strength bilaterally. Which assessment finding would be most concerning and require immediate intervention?
What is a change in level of consciousness or acute neurological status? Changes in LOC are the earliest and most sensitive indicators of neurological deterioration and warrant immediate evaluation.
A patient has unilateral leg swelling with increased calf circumference compared with the opposite leg. What potential complication should the nurse recognize?
What is deep vein thrombosis (DVT)?
A nurse notes capillary refill greater than 3 seconds. What should the nurse suspect?
What is decreased peripheral perfusion?
A patient complains of right lower quadrant pain and guarding at McBurney's point. What condition is most likely?
What is appendicitis?
A patient cannot distinguish sharp from dull sensations in the lower extremities. Which system requires further assessment?
What is sensory function?
A client with a history of liver cirrhosis presents with a markedly distended abdomen and increasing shortness of breath when lying flat. During assessment, the nurse notes bulging flanks and shifting dullness. What is the most likely cause of the client's respiratory difficulty?
What is ascitic fluid increasing intra-abdominal pressure, causing diaphragmatic elevation and decreased lung expansion?
A client's family reports that the client can understand conversations but becomes frustrated because the client is unable to form words and speaks only in short phrases. Which neurological finding best explains this assessment?
What is Broca's aphasia? Clients with Broca's aphasia generally understand language but have difficulty producing speech.
A nurse documents a pulse as 1+. How should this finding be interpreted?
What is a weak pulse that may indicate decreased cardiac output or increased peripheral vascular resistance?
A patient reports new confusion. Which neurological finding should concern the nurse most?
What is a change in level of consciousness?
A patient with ulcerative colitis develops severe diarrhea and dizziness. What complication should the nurse prioritize?
What is dehydration with electrolyte imbalance?
A patient suddenly develops slurred speech, weakness, and confusion. What nursing action has the highest priority?
What is immediate neurological evaluation and activation of stroke protocols?
A nurse is assessing a patient with bilateral ankle edema after a high-sodium diet and poor fluid management. Which teaching should the nurse prioritize?
What is reducing sodium intake and promoting hydration management?
A 68-year-old client reports left lower quadrant abdominal pain that worsens when coughing or lifting. During the assessment, the nurse notes abdominal tenderness, and the client reports intermittent constipation and dark, tarry stools. Which condition should the nurse suspect?
What is diverticulitis? Diverticulitis occurs when diverticula become inflamed and is commonly associated with left lower quadrant pain, tenderness, and changes in bowel habits. Melena may also occur if bleeding is present.