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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevated troponins are the most specific and sensitive markers for myocardial injury. Troponin I and Troponin T levels rise within a few hours of an AMI and remain elevated for days, confirming cardiac damage.
B. Elevated hemoglobin is not an indicator of cardiac injury. Hemoglobin levels are used to assess oxygen-carrying capacity and anemia.
C. Elevated B-type natriuretic peptide (BNP) is a marker for heart failure, not acute myocardial infarction.
D. Elevated creatine kinase (CK), particularly CK-MB, can indicate muscle injury, including cardiac injury, but it is less specific than troponins for diagnosing AMI.
Correct Answer is D
Explanation
A. A high HDL level (above 60 mg/dL) is protective against cardiovascular disease and does not contribute to hypertension.
B. A regular exercise routine is beneficial for cardiovascular health and helps lower blood pressure rather than increasing it.
C. Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension rather than causing it.
D. Obstructive sleep apnea (OSA) is a known risk factor for hypertension due to intermittent hypoxia and increased sympathetic nervous system activity, which contribute to elevated blood pressure.
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