A nurse is caring for a client with a history of an abdominal aortic aneurysm (AAA). Which of the following assessments should be the nurse's priority for a client with an abdominal aortic aneurysm?
Deep palpation of the abdomen
Review of chest x-ray
Assessing the client’s pain
Assessment of blood pressure
The Correct Answer is D
A. Deep palpation of the abdomen is contraindicated in clients with an AAA, as it may cause rupture.
B. A chest X-ray may detect an aneurysm, but it is not the priority assessment.
C. Pain assessment is important, as sudden severe pain could indicate rupture, but it is not the first priority.
D. Blood pressure assessment is the priority, as hypertension can increase the risk of aneurysm rupture. Strict BP control is critical to preventing complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.
Correct Answer is C
Explanation
A. A prolonged PR interval can be seen in hyperkalemia but is not as characteristic as peaked T waves.
B. A U wave is typically seen in hypokalemia, not hyperkalemia.
C. Peaked T waves are a hallmark ECG finding in hyperkalemia and occur due to increased repolarization speed.
D. ST segment elevation is more commonly associated with myocardial infarction rather than hyperkalemia.
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