A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

An abdominal aortic aneurysm is commonly found in the suprarenal aorta.

An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery.

An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.

Abdominal aortic aneurysms might rupture if blood pressure is too low.

Answer and Explanation

The Correct Answer is C

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta: This statement is incorrect. Abdominal aortic aneurysms (AAAs) are most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal region.

B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery: This statement is incorrect. An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm.

C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter: This statement is correct. An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition.

D. Abdominal aortic aneurysms might rupture if blood pressure is too low: This statement is incorrect. Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture.

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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.

A. Apply soft restraints to wrists and chest. B. Administer antipsychotic medications as prescribed. C. Administer sedative medications as prescribed. D. Arrange for one-on-one observation for the client.

Correct Answer is D

Explanation

A. Apply soft restraints to wrists and chest: Using restraints should only be considered as a last resort and should not be the first intervention for managing delirium. Restraints can exacerbate agitation and increase the risk of complications such as skin breakdown, musculoskeletal injury, and psychological distress. Therefore, applying restraints should not be the first action taken by the nurse.

B. Administer antipsychotic medications as prescribed: While antipsychotic medications may be used to manage symptoms of delirium in some cases, they should not be the first intervention for preventing client injury. Additionally, the use of antipsychotics in the ICU requires careful consideration due to potential adverse effects, such as sedation, hypotension, and prolongation of the QT interval. The decision to administer antipsychotic medications should be based on a comprehensive assessment and in consultation with the healthcare team.

C. Administer sedative medications as prescribed: Administering sedative medications may help calm an agitated client with delirium, but it should not be the first intervention for preventing client injury. Sedatives can further impair cognition and increase the risk of falls or other complications. Like antipsychotic medications, the use of sedatives should be based on a thorough assessment and in collaboration with the healthcare team, rather than being the initial action taken by the nurse.

D. Arrange for one-on-one observation for the client: Delirium in the intensive care unit (ICU) is a serious condition that can lead to confusion, disorientation, and an increased risk of injury to the client. The priority intervention for preventing client injury in this situation is to ensure constant monitoring and supervision. By arranging for one-on-one observation, the nurse can provide continuous monitoring of the client's behavior, assess for changes or signs of agitation, and intervene promptly to prevent falls or other injuries.

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A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

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Correct Answer is ["B","C"]

Explanation

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