The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?
“I have stomach pain every time I eat a big, heavy meal."
“I don't have any abdominal pain or any type of problems."
“I have periodic episodes of constipation and then diarrhea."
“I belch a lot especially when I lay down after eating"
The Correct Answer is B
Abdominal aortic aneurysms (AAA) often do not present with specific symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common finding during the assessment of a client with an abdominal aortic aneurysm.
Let's briefly review the other statements:
"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reflux rather than specifically related to an abdominal aortic aneurysm.
"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.
"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reflux or gastroesophageal reflux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain first. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.
A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.
Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood flow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.
The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.
Correct Answer is D
Explanation
Choice D: This question is crucial as it addresses the client's adherence to their prescribed medication regimen for managing high blood pressure. Consistent medication use is essential for controlling blood pressure and reducing the risk of complications associated with hypertension. The elevated blood pressure reading suggests that the current medication regimen may not be effectively controlling the client's blood pressure. By assessing medication adherence, the nurse can determine if non-adherence is contributing to the high blood pressure reading or if adjustments to the medication regimen are required.
"Have you recently taken any antihistamines?": Asking about recent antihistamine use is not directly relevant to the client's high blood pressure reading of 210/106 mm Hg. Antihistamines are medications primarily used to relieve allergy symptoms and do not typically have a significant impact on blood pressure levels.
"Have there been recent stressful events in your life?": While stress can contribute to temporary increases in blood pressure, asking about recent stressful events is not the most critical follow-up question in this situation. The client's blood pressure reading of 210/106 mm Hg indicates a severe elevation that requires immediate attention and management beyond stress reduction alone.
"Did you take any acetaminophen today?": Acetaminophen, also known as paracetamol, is a pain reliever and fever reducer. It does not typically have a significant effect on blood pressure. Therefore, asking about acetaminophen use is not the most relevant follow-up question for the client's high blood pressure reading.
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