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

Answer and Explanation

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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Correct Answer is C

Explanation

A. First-degree heart block has a regular R-R interval, meaning the rhythm is typically regular.
B. The presence of P waves is a distinguishing feature of first-degree heart block. Absent P waves are more characteristic of atrial fibrillation or junctional rhythms.
C. First-degree heart block is characterized by a prolonged PR interval greater than 0.20 seconds, but all impulses are still conducted to the ventricles.
D. A progressively lengthening PR interval followed by a dropped QRS complex is indicative of second-degree Mobitz Type I (Wenckebach) heart block, not first-degree heart block.

A. Dyspnea B. Anorexia C. Malaise D. Fever

Correct Answer is A

Explanation

A. Dyspnea is the priority finding as it may indicate heart failure or pulmonary embolism, both of which are life-threatening complications of infective endocarditis.
B. Anorexia is a common symptom but is not an immediate threat to the client's condition.
C. Malaise is a general symptom of infection but does not require urgent intervention.
D. Fever is a hallmark sign of infection but is not as critical as assessing for complications such as heart failure or embolic events.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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