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 B
Explanation
A. While cardiac rehab does help recovery, this statement does not emphasize the safety and long-term benefits of supervised rehabilitation.
B. Providing education about the role of cardiac rehab is essential. Cardiac rehab monitors the client's progress and helps safely return them to an active lifestyle.
C. While this statement acknowledges the client's feelings, it does not provide enough information about the benefits of cardiac rehab.
D. This response is too authoritative and does not address the client’s concerns or autonomy.
Correct Answer is D
Explanation
A. Complete heart block (third-degree AV block) is characterized by a complete dissociation between atrial and ventricular activity, with P waves and QRS complexes occurring independently of each other.
B. Sinus tachycardia presents with a regular rhythm, a heart rate above 100 beats per minute, and distinct P waves preceding each QRS complex.
C. Idioventricular rhythm occurs when the heart's primary pacemakers fail, leading to a slow ventricular rate (usually 20-40 bpm) with wide QRS complexes and no preceding P waves.
D. Ventricular tachycardia (VT) is a life-threatening arrhythmia characterized by a rapid ventricular rate (typically >100 bpm), wide QRS complexes, and an absence of P waves. VT can be sustained or non-sustained and may require immediate intervention if the patient is unstable.
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