A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?
Lower back or groin pain
Hunger after eating
Pain in the chest
Presence of Cullen's sign
The Correct Answer is A
A. Lower back or groin pain: Lower back or groin pain can be an early manifestation of an abdominal aortic aneurysm (AAA). This pain may result from pressure exerted by the enlarging aneurysm on surrounding structures or from irritation of nerves as the aneurysm expands. As the aneurysm enlarges, the pain may become more severe and persistent.
B. Hunger after eating: Hunger after eating is not typically associated with an abdominal aortic aneurysm. This symptom may be indicative of various gastrointestinal issues such as peptic ulcer disease or gastritis, but it is not a characteristic manifestation of AAA.
C. Pain in the chest: While AAA can lead to compression of nearby structures, resulting in referred pain, chest pain is not a common early manifestation of an abdominal aortic aneurysm. Chest pain is more commonly associated with cardiac issues such as angina or myocardial infarction.
D. Presence of Cullen's sign: Cullen's sign refers to periumbilical bruising, which can occur due to retroperitoneal hemorrhage from a ruptured AAA. However, Cullen's sign is not an early manifestation of an AAA; it is typically observed in more advanced cases or after rupture has occurred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Limit exercise to 10 min, 2 days per week. This recommendation is incorrect. Regular physical activity is essential for heart health. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity aerobic exercise per week, spread throughout the week.
B. Monitor blood pressure This recommendation is correct. Monitoring blood pressure is an essential aspect of heart disease prevention. High blood pressure (hypertension) is a significant risk factor for heart disease, so regular monitoring allows for early detection and management.
C. Lose weight if necessary. This recommendation is correct. Maintaining a healthy weight or losing weight if overweight or obese is important for heart disease prevention. Excess weight, especially around the abdomen, increases the risk of heart disease and other health conditions.
D. Eat a diet high in saturated fats. This recommendation is incorrect. A diet high in saturated fats is associated with an increased risk of heart disease. Instead, the nurse should encourage a heart-healthy diet that includes fruits, vegetables, whole grains, lean proteins, and healthy fats.
E. Maintain current cholesterol level This recommendation is not entirely accurate. While maintaining healthy cholesterol levels is important for heart health, individuals with high cholesterol levels may need to take steps to lower their cholesterol through lifestyle modifications and, in some cases, medication. Therefore, simply maintaining current cholesterol levels may not be sufficient for heart disease prevention.
Correct Answer is C
Explanation
A. Isolated: This term refers to something that is separate or distinct. Confusion and agitation in a client are not typically isolated but can be part of a broader clinical picture.
B. Permanent: These manifestations are not typically permanent and can often be reversed with appropriate interventions.
C. Reversible: Confusion and agitation in a client are often reversible and can be due to various factors such as medications, infections, metabolic disturbances, or other medical conditions. Identifying and addressing the underlying cause can often restore the client to their baseline mental status.
D. Unique: While every individual's presentation may have unique aspects, confusion and agitation are not considered unique manifestations in the context of acute changes in mental status. They are common symptoms that can occur due to a variety of reasons and are not exclusive to any particular condition.
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