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Cardiovascular - Book 1

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Coronary artery perfusion is dependent upon:
A. Diastolic pressure
B. Systolic pressure
C. Afterload
D. Systemic vascular resistance
A. Diastolic pressure
Diastolic pressure in the aortic root is higher than left ventricular end diastolic pressure (LVEDP) (the pressure exerted on the ventricular muscle at the end of diastole when the ventricle is full). This enables blood to flow from a higher pressure through open arteries to a lower pressure. This pressure gradient is known as coronary artery perfusion pressure. As diastolic pressure drops, there is a decrease in coronary artery blood flow.
Mixed venous oxygen saturation (SvO2) assesses:
A. Preload
B. Afterload
C. Oxygen delivery
D. Oxygen consumption
D. Oxygen consumption
Mixed venous oxygen is measured in the pulmonary artery and measures the oxygen saturation of blood that has passed through the entire circulatory system. Therefore, it is measuring the oxygen that has been consumed by the tissues.
Normal mixed venous oxygen saturations are:
A. 30-40%
B. 20-45%
C. 80-100%
D. 60-80%
D. 60-80%
Mixed venous saturations obtained from the pulmonary artery reflect the venous oxygenation of blood that has delivered oxygen to all the tissues of the body. Normal adult oxygen consumption is approximately 25%. The range of normal oxygen usage is then measured by mixed venous saturations and for adult the normal range is 60-80%.
The Intra-Aortic Balloon Pump (IABP) has the following hemodynamic effects:
A. Increases left ventricular pressure
B. Increases wedge pressure
C. Increases coronary artery perfusion
D. Increases afterload
C. Increases coronary artery perfusion
The major hemodynamic effects of the IABP are increased coronary artery perfusion and decreased afterload. It improves perfusion and decreases the workload of the myocardium. The IABP improves coronary artery perfusion by increased diastolic pressure, thereby improving coronary perfusion pressure
Intra-aortic balloon pump (IABP) therapy is contraindicated for which of the following disorders:
A. Papillary muscle rupture
B. Incompetent aortic valve
C. Left ventricular failure
D. Unstable angina refractory to medical therapies
B. Incompetent aortic valve
If the aortic valve is insufficient, blood continually leaks back from the aorta into the left ventricle. If the IABP is present, it will increase the insufficiency and cause worsening left ventricular failure. It can possibly cause the ventricle to rupture due to over dilatation.
When listening to heart sounds, the fourth heart sound (S4):
A. Occurs after ventricular contraction
B. Is best heard with the diaphragm of the stethoscope
C. Is a normal finding in children
D. Occurs during late diastole when the atria contracts
D. Occurs during late diastole when the atria contracts
The presence of the extra heart sound S4 signifies a poorly compliant (stiff) left ventricle. An S4 is also called an atrial heart sound since it occurs at the end of diastolic filling when the atria contracts and fully fills the left ventricle. Known as atrial kick, this filling is important to cardiac output. When the left ventricle is stiff (decreased compliance-with long term htn, aortic stenosis, or with acute STEMI) the atria has to pump harder to move blood from the atria to the ventricle causing a turbulent blood flow and causing the extra heart sound. This heart sound is always pathologic.
The pathologic changes found on the 12 lead ECG that indicates myocardial ischemia are:
A. ST elevation
B. ST segment depression and T wave elevation
C. Q wave formation
D. ST segment depression and T wave inversion
D. ST segment depression and T wave inversion
Myocardial ischemia changes the repolarization of the ventricular muscle and that change is seen on the 12 lead ECG as ST segment depression and T wave inversion demonstrates subendocardial ischemia- the inner most layer of muscle in the myocardium
Positive inotropic agents are used to:
A. Improve cardiac output and tissue perfusion
B. Decrease water loss through the kidney
C. Increase heart rate
D. Vasodilate vessels
A. Improve cardiac output adn tissue perfusion
The term inotropic means affecting the force of myocardial contraction. Improvement of cardiac muscle contraction leads to an improved cardiac output and tissue perfusion
Chronic stable angina is best described as angina that:
A. Increases over time
B. Is new to the patient
C. Occurs at rest
D. Has a predictable pattern over time
D. Has a predictable pattern over time
Chronic (meaning presenting over a long period of time) stable angina is defined as chest pain that occurs with predictable activity or exertion that is treated with rest and nitroglycerin. ECG at time of pain is normal and there is no increase in bio-markers indicating no necrosis of tissue. The pain is predictable and is relieved in a predictable method making this type of angina "stable" over time.
The two major components that determine blood pressure are:
A. Systemic vascular resistance (SVR) and cardiac output
B. Contractility and systemic vascular resistance (SVR)
C. Preload and afterload
D. Contractility and afterload
A. Systemic vascular resistance (SVR) and cardiac output
The equation for blood pressure is: BP= arterial resistance (SVR) X cardiac output
The layer of arterial vessel wall responsible for changes in the diameter of the artery is the :
A. Media
B. Initima
C. Externa
D. Adventitia
A. Media
The media layer of the arterial wall contains vascular smooth muscle cells and is responsible for arterial tone. Vasoactive substances released in response to the sympathetic nervous system and/or renin-angiotensin system determine arterial tone.
Activation of the renin-angiotension system results in:
A. Arterial vasoconstricion and decreased retention of sodium and water
B. Arterial vasodilation and decreased retention of sodium and water
C. Arterial vasoconstriction and increased retention of sodium and water
D. Arterial vasodilation and increased retention of sodium and water
C. Arterial vascocontriction and increased retention of sodium and water.
Stimulation of the renin-angiotension system activates teh angiotension II receptors causing severe vasoconstriction with shunting of blood to the heart, brain and diaphragm. When renin is released from the kidney it also causes increased aldosterone secretion thereby increasing retention of sodium and water in the long hoop of Henle
A pt noted to be in acute distress with rales auscultated half way up both lungs, the extremities are cool and diaphoretic, jugular venous distension is noted, oxygen saturations are 95% and the pt c/o SOB. Which assessment corresponds to the pt cardiac status?
A. No pulmonary congestion with normal perfusion
B. Pulmonary congestion with normal perfusion.
C. Pulmonary congestion with low perfusion
D. No pulmonary congestion with low perfusion
C. Pulmonary congestion with low perfusion
Rales indicate fluid in the alveolar sacs, possibly secondary to pulmonary edema (PNA can also cause fluid in alveolar sacs). This causes pulmonary congestion. The pt is c/o SOB and their o2 sat are lowering, also indicating that the pt has pulmonary congestion. The pt skin is cool and diaphoretic, indicating that the skin is poorly perfused. Skin is a non-oxygen requiring organ and shunts blood away early in decreased cardiac function
When listening to heart sounds, S1 signifies:
A. The beginning of ventricular systole
B. The beginning of ventricular diastole
C. Propulsion of blood into a non-complaint ventricle
D. That blood going in the wrong direction
A. The beginning of ventricular systole
The S1 heart sound indicates the opening of the aortic and pulmonic valves and marks the beginnning of ventricular systole or ejection
A patient with pulmonary edema has impaired diffusion due to:
A. Increased thickness of the alveolar capillary membrane
B. Retention of PCO2
C. An elevated body temperature associated with pulmonary edema
D. Low barometric pressure
A. Increased thickness of the alveolar capillary membrane.
With increasing left ventricular pressure, blood moves back into the left atrium then to the pulmonary veins. When the pressure in the pulmonary veins increases, capillary function decreases and fluid then shifts to the interstitial space causing interstitial edema, thereby increasing the thickness of the space oxygen must travel. When left ventricular pressures increases more, the fluid then shifts to the alveolar space causing pulmonary edema. This fluid acts as a deterrent to oxygen diffusion.
A patient with an anterior wall STEMI is in cardiogenic shock. What would the hemodynamic profile assessment be?
A. Decreased cardiac index, increased preload and increased afterload
B. Decreased cardiac index, decreased preload and increased afterload
C. Increased cardiac index, decreased preload and decreased afterload
D. Decreased cardiac index, decreased preload and decreased afterload
A. Decreased cardiac index, increased preload and increased afterload
In the pt with cardiogenic shock, preload and afterload are increased. This is caused by the severe vasocontriction of both on the venous and arterial side. Arterial vasoconstriction causes increased systemic vascular resistance (SVR) and lowers cardiac index. Because the ventricle is failing and contractility is also low, the left ventricular pressures increase, causing blood to increase in the pulmonary bed. This leads to increased Rt ventricular pressures and central venous pressures (CVP). In heart failure, there is an increse in preload, afterload and a decrease in cardiac index and contractility.
Without hemodynamic monitoring available, how do you assess systemic vascular resistance (SVR)?
A. Diastolic blood pressure
B. Systolic blood pressure
C. Heart rate and respiratory rate
D. Capillary refill
A. Diastolic blood pressure
With increased SVR, the patient's diastolic BP will go up. The diastolic blood pressure is a reflection of the arterial tone. With increaseing arterial tone (increased SVR) the diastolic pressure will go up and the pulse pressure will narrow
A medication that dilates both the venous and arterial beds will casue?
A. Increased preload and decreased afterload
B. Increased preload and increased afterload
C. Decreased preload and decreased afterload
D. Decreased preload adn increased afterload
C. Decrease preload and decrease afterload
When both the venous and arterial bed are dilated there will be less venous return causing a decreased preload (ex. nitroglycerin). With arterial vasodilation, the SVR will decrease and therefore cause afterload (afterload is determined by SVR) to decrease (ex. nitroprusside).
The gold standard diagnostic tool for identification, location and severity of coronary artery disease is:
A. Stress test
B. Echocardiography
C. Cardiac catherization
D. A spiral computer tomography (CT scan)
C. Cardiac catherization
The best diagnostic tool for the diagnosis, location of disease and severity of CAD is the cardiac cath performed in the cath laboratory.
The common complication after a STEMI is:
A. heart failure
B. dysrhythmias
C. ventricular septal rupture
D. vetnricular wall rupture
B. dysrhythmia
due to irritabililty of the ischemic myocardium and the dead myocardium that does not transmit electrical stimuli. With an inferior wall STEMI, the most common dysrhythmia is bradycardia and heart block, with anterior wall STEMI, it is tachy-dysrhythmias such as ventricular tachycardiaa and/or ventriculare fibrillation.
The most common cause of heart failure in the United States is:
A. Valvular disease
B. Ischemic heart disease
C. Renal failure
D. Hepatitis
B. Ischemic heart disease
After STEMI or NSTEMI with damage to the myocardium, ventriular failure may result secondary to decreased ejection fraction
Systolic left ventricular dysfunction is best defined as:
A. Impaired ability of the left ventricle to contract and effectively eject blood
B. Impaired ability of the left ventricle to fill and relax
C. Heart failure with an elevated systolic blood pressure
D. Heart failure in which the heart stops beating
A. Impaired ability of the left ventricle to contract and effectively eject blood
Systolic function occurs when the ventricle has lower contractility and produces a lower ejection fraction and cardiac output. The ventricle dilates and loses teh ability to contract as a unit. Depending on severity of hte dysfunction, the patient may present in cardiogenic shock.
Neurohormonal response in heart failure with long-term consequences includes:
A. Increased release of glycogen stores from the liver
B. Increased activation of the sympathatic nervous system and renin-angiotension system
C. Increased production of hemoglobin
D. Increased production of cholesterol to make more hormones
B. Increased activation of the sympathetic nervous system and the renin-angiotension system
With continued heart failure, the body compensates for the low cardiac output by stimulating the sympathetic nervous system and the renin-angiotension system. This increases preload and afterload in an already poorly functioning heart. Neurohormonal blockers are the treatment (beta-blockers and angiotension converting enxyme inhibitor drugs).
Medications commonly used in the treatment of heart failure include:
A. Angiotension converting enzyme inhibitors and beta blockers
B. Calcium channel blockers
C. Nitrates
D. Calcium channel blockers and digoxin
A. ACE inhibitors and beta blockers.
The most effective and evidence based practice treatment of heart failure is neurohormomal blockade. These medications include: beta blockers, and ACE inhibitors. They reduce preload and afterload, control heart rate and blood pressure as well.
Aldosterone antagonists are contraindicated in the following conditions.
A. A serum creatinine of 4.0 or greater
B. A serum potassium of 2.9 or less
C. A serum creatinine of 1.5 or more
D. A serum glucose above 200
A. A serum creatinine of 4.0 or greater
Aldosterone antagonists block aldosterone production. Aldosterone stimulate sodium reabsorption and water retention. By blocking this, it reduces water retention in the heart failure patient. A contraindication for use would be elevated creatinine because this class of medications are potassium sparing drugs that would increase creatinine and potassium. This in turn would put the patient at risk for hyperkalemia and acute renal injury and/or failure.
The heart's primary compensatory response to chronic aortic stenosis includes:
A. Left atrial hypertrophy
B. Left ventricular hypertrophy
C. Left ventricular dilation
D. Right ventricular dysfunction
B. Left ventricular hypertrophy
With chronic aortic stenosis, the left ventricle hypertrophies over time due to the increased work load of pumping blood through a narrowed opening. This leads to diastolic dysfunction as well as hypertrophy.
Nursing interventions for the patient with pericarditis include all the following EXCEPT:

A. providing comfort by administering pain medications and proper positioning
B. Auscultating heart sounds to assess for muffling.
C. Administering anticoagulants to prevent thrombus in the pericardium
D. Monitoring for jugular venous distension and hypotension
C. Administering anticoagulants to prevent thrombus in the pericardium

In the face of pericarditis, the nurse should provide pain relief, auscultate heart sounds, be on the alert for signs of tamponade (tachycardia, narrowed pulse pressure and hypotension with increased jugular venous distension). The patient should not receive systemic anticoagulation. Anticoagulation may increase the possibility of hemorrhage into the pericardium.
Patients with pericardial effusions should be assessed for the development of which of the following complications?

A. Thrombocytopenia
B. Tamponade
C. Decreased hemoglobin and hematocrit
D, Endocarditis
B. Tamponade

Any patient with a pericardia effusion should be assessed for cardiac tamponade physiology. Any accumulation of fluid in the pericardial sac can compress the myocardium producing tamponade signs and symptoms.
Epinephrine is indicated as the first line drug for any pulseless condition because it has the following actions:

A. Positive inotrophy and selective shunting of blood to the brain and heart
B. Conversion of ventricular fibrillation to a sinus rhythm
C. Slowing of the heart rate and improvement of contractility
D. Decreased cardiac contractility
A. Positive inotrophy and selective shunting of blood to the brain and heart

Epinephrine is a pure catecholamine that increases contractility as well as causing vasoconstriction that shunts blood to heart, brain and diaphragm. According to advanced cardiac life support, it is the drug of choice for any pulseless arrest.
The most common postoperative complication of coronary artery bypass grafting (CABG) surgery is:

A. Bleeding
B. Stroke
C. Atrial Fibrillation
D. Ventricular fibrillation
C. Atrial fibrillation

The most common complication after CABG is the dysrhythmia atrial fibrillation will occur. In approximately 33% of post CABG patients, atrial fibrillation will occur. Post operative myocardial edema and pulmonary water cause an increase in pulmonary pressures. This, combines with a stiffened ventricle lead to atrial fibrillation.
A patient returns to the operating room after coronary artery bypass grafting (CABG). Filling pressures are normal, the heart rate is 60 beats per minute, and the cardiac index is 1.7 l/m/m2. Which of the following actions would the critical care nurse anticipate to increase the cardiac index?

A. Administer crystalloid fluid boluses
B. Administer packed red blood cells
C. Prepare to open the chest
D. Initiate pacing to increase the heart rate
D. Initiate pacing to increase the heart rate

Post operatively, CABG patients have pacing wires that allow external pacing. Since cardiac index equals heart rate times stroke volume, and the patient's filling pressures are normal (meaning no fluid is needed, preload is adequate), the action should be to pace the patient at a higher rate.
In a patient with chronic obstructive pulmonary disease (COPD) and heart failure, the hemodynamic assessment will most likely reveal [CVP= central venous pressure, CI= cardiac index, PAP=pulmonary artery pressure]:

A. Low CVP, Low CI and low PAP
B. Low CVP, low CI and high PAP
C. High CVP, low CI and low PAP
D. High CVP, low CI and high PAP
D. High CVP, low CI and high PAP

In the patient with COPD, there will be elevated PAPs secondary to pulmonary hypertension from the disease. heart failure would indicate a low CI and an elevated CVP - secondary to pulmonary hypertension and fluid overload.
In a postoperative coronary artery bypass graft (CABG) patient, the central venous pressure (CVP), pulmonary artery pressure (PAP) and wedge pressure all equalize and the patient is becoming severely hypotensive. These findings may indicate:

A. Cardiac tamponade
B. Low potassium
C. Low calcium
D. Normal immediate post operative course
A. Cardiac tamponade

In the immediate post operative period, hypotension with elevated and equalizing intracardiac pressures indicate a tamponade physiology. Blood in teh pericardium compresses the hear and causes a restrictive cardiomyopathy reducing cardiac index.
In a patient with cardiogenic shock, the nurse should anticipate which of the following actions?

A. Placement of an intra-aortic balloon pump (IABP), contractility medications, preload reducers, and afterload reducers
B. Because of the high mortality associated with this condition, palliative measures are instituted.
C. Contractility medications, preload enhancers, and afterload reducers
D. Drugs that reduce contractility, increase perload, decrease afterload and correct calcium levels
A. Placement of an intra-aortic balloon pump (IABP), contractility medications, preload reducers, and afterload reducers

The patient in cardiogenic shock requires lowered preload, lowered afterload, drugs that improve contractility and insertion of IABP, All of these methods will increase cardiac index and improve end organ perfusion.
A non-ST segment myocardial infarction (NSTEMI) is differentiated from unstable angina by:

A. Location of the chest pain
B. Cardiac biomarkers
C. Electrocardiogram (ECG) changes
D. Extensive cardiac history
B. Cardiac biomarkers

In the NSTEMI versus the unstable angina patient, the location of the pain may be the same. Both will have ST-T wave depression **********ociated leads on the ECG. The history of the patient with myocardial ischemia is unlikely to be pertinent for differentiation of these syndromes, In unstable angina, the patient any have ECG changes, but no cardiac enzyme changes. In NSTEMI, the patient will have cardiac enzyme elevation.
The nurse auscultates and S3 heart sound on a patient just admitted with a non-ST segment myocardial infarction (NSTEMI). What does that indicate?

A. Normal heart sounds
B. Mitral valve stenosis
C. Fluid overload
D. Increased afterload
C. Fluid overload

The auscultation of an S3 heart sound is always abnormal in the adult patient. It indicates an overfilled left ventricle at the beginning of ventricular diastole and is a marker of poor ventricular function as well as fluid overload.
The primary function of drug therapy with beta-blockers in heart failure is to:

A. Increase blood pressure
B. Block compensatory vasoconstriction and increased heart rate
C. Increase urine output
D. Decrease preload
B. Block compensatory vasoconstriction and increased heart rate

The treatment of heart failure is to reduce the actions of the sympathetic nervous system (SNS) and the renin-angiotensin system. Beta blockers block the SNS and reduce afterload, slightly reduce contractility and heart rate regulation. These decrease the demands of oxygen for the patient with reduced ventricular function.
Early symptoms of fluid overload and pulmonary edema include:

A. Auscultation of rales and hypoxia
B. Auscultation of an S3 heart sound and tachycardia
C. Complaints of shortness of breath and orthopnea
D. ST-segment elevation in the chest leads
C. Complaints of shortness of breath and orthopnea

A symptom is something the patient complains of rather than objective findings noted by the nurse. Shortness of breath and orthopnea are symptoms verbalized by the patient. Rales, hypoxia, S3heart sounds and tachycardia are objective findings noted by the nurse. ST-segment elevation is a sign of cardiac injury/infarction. A complaint of shortness of breath and the inability to lie down are symptoms of early left ventricular failure.
Positive inotropic agents are used to:

A. Improve tissue perfusion
B. Decrease water loss through the kidney
C. Increase heart rate
D. Vasodilate vessels
A. Improve tissue perfusion

Inotropic agents are used to improve contractility of the myocardium, thereby improving ventricular function and cardiac output/index. improved index will increase tissue perfusion
After cardiac transplantation, the patient is placed on cyclosporine. In assessing this patient, the nurse should monitor:

A. Blood glucose
B. Serum creatinine
C. Serum amylase
D. Serum magnesium
B. Serum creatinine

When a patient is on cyclosporine for antirejection, serum creatinine should be followed closely. Cyclosporine is elininated via the kidney and can cause renal injury and failure. Of course, blood sugar should be monitored, however, this question is looking for the consequence of a drug on renal function.
A postoperative patient is admitted to the unit after undergoing a coronary artery bypass graft (CABG). Bleeding is noted from the patient's chest tube. The critical care nurse knows that the physician should be notified when blood loss:

A. Exceeds 50 ml over one hour
B. Is 250 ml over four hours
C. Is present
D. Exceeds 200ml/hour over two hours
D. Exceeds 200ml/hour over two hours

According to AACN procedure manual, the nurse should notify the physician if the chest tube output exceeds 200 ml/hour for 2 consecutive hours. (In practice, this is dictated by the physician)
The formula for oxygen delivery is dependent upon several factors including oxygen content. Which of the following has a direct impact on arterial oxygen content?

A. Hemoglobin
B. SvO2
C. Serum calcium
D. Serum lactate
A. Hemoglobin

Hemoglobin is a major component in the formula determining oxygen delivery, Oxygen combines with hemoglobin for transport and delivery. SvO2 is venous oxygenation and helps to determine the amount of oxygen consumed by the body. Serum calcium is important for ventricular contraction and function but is not considered in oxygen delivery. Serum lactate is a product of anaerobic metabolism and may indicate a lack of oxygen delivery.
The physiologic reason for sinus tachycardia is:

A. Increased serum potassium
B. Elevated creatinine
C. Decreased urine output
D. Tissue hypoxia
D. Tissue hypoxia

Sinus tachycardia is generally a compensatory mechanism for decreased tissue oxygenation. Fever, pain, anxiety, hypervolemia, hypovolemia and a decreased blood pressure are all reasons for tachycardia: the physiology in all of these is the lack of enough oxygen delivery at the tissue level.
A patient is admitted with decompensated heart failure. The patient is receiving Furosemide (Lasix), Digoxin (Lanoxin), Metoprolol (Lopressor), and Lisinopril (Zestril, Prinivil) at home. What drug can be added to reduce preload?

A. Spirinolactone (Aldactone)
B. Calcium Channel Blocker
C. Pradaxa (dabigatran)
D. No other drugs are essential
A. Spirinolactone (Aldactone)

When the heart failure patient continues to have volume overload on appripriate medications, an aldosterone inhibitor should be added. Aldosterone inhibition will decrease sodium reabsorption from the kidney and therefore decrease intravascular volume. The nurse would carefully monitor potassium since aldosterone blockers are potassium-sparing diuretics.
Which condition would stimulate renin production?

A. Increased blood supply to the renal tubules
B. Decreased blood pressure
C. Decreased sympathetic output
D. Increased sodium concentration
B. Decreased blood pressure

Renin secretion is regulated by blood flow to the juxtaglomerular apparatus. Decreased blood pressure would be identified and renin secretion would occur; this begins a compensaroty mechanism that causes vasoconstriction with increased blood pressure as well as sodium and water reabsorption in the kidney, thereby effectively increasing blood pressure.
Acute endocarditis of the mitral valve causes:

A. Symptoms similar to heart failure
B. Symptoms of severe chest pain mimicking STEMI
C. Claudication-type pain
D. Pain that is relieved by sitting up
A. Symptoms similar to heart failure

Symptoms of acute endocarditis are very similar to heart failure since the patient is in heart failure. The mitral valve with infection may become incompetent and cause increase pulmonary pressures just like left ventricular heart failure. The patient will need heart failure treatment as well.
In a patient with sever asthma and left ventricular failure, the expected hemodynamic profile would demonstrate:

A. Low cardiac index, high heart rate and low wedge pressures
B. High cardiac index, high heart rate, and low wedge pressures
C. Low cardiac index, high heart rate, and high wedge pressures
D. Normal cardiac index, normal heart rate and high wedge pressures
C. Low cardiac index, high heart rate, and high wedge pressures

The patient with severe asthma will have high pulmonary pressures. With failure the patient would then also have low cardiac index and high wedge pressures (left ventricular failure will increase the wedge demonstrating poor left ventricular function and fluid overload).
With acute arterial insufficiency, the extremity will appear:

A. Warm with normal color
B. Warm with increased redness
C. Cool with pale color
D. Cool with normal color
C. Cool with pale color

The patient with acute arterial insufficiency will have a cool extremity (due to lack of blood flow) and a pale appearance (again due to lack of blood flow). The 6P's to arterial circulation are: pulse (palpation or Doppler), pain (patients perception), pallor (color change), polar (decreased temperature), paresthesia (numbness, pins and needles sensation in the extremity) and paralysis (not feeling or moving).
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