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"

Answer and Explanation

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.

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Correct Answer is D

Explanation

Monitoring a client after a transesophageal echocardiogram involves observing the client for any immediate post-procedure complications or adverse reactions. This may include assessing vital signs, monitoring for signs of bleeding or infection, and reporting any concerning symptoms or changes in the client's condition to the nurse.

Checking the client's catheter site after a coronary angiogram requires assessing the site for bleeding, hematoma, or signs of infection. This task involves more complex assessment skills and would typically be performed by the nurse.

Teaching a patient about exercise electrocardiography involves providing education on the purpose of the test, the procedure itself, and any preparation or precautions the patient needs to take. This task requires specialized knowledge and is best performed by the nurse who can address the patient's specific questions and concerns.

Attaching ECG monitoring electrodes after a patient bathes requires technical knowledge and skill in properly placing the electrodes and ensuring accurate ECG readings. This task also falls within the scope of the nurse's responsibilities.

Delegation should be based on the UAP's skill set, training, and the complexity of the task. While the UAP can provide valuable support in monitoring a client after a transesophageal echocardiogram, the other tasks mentioned require the expertise and knowledge of a nurse.

A. Most people are able to control BP through dietary changes. B. Increasing physical activity controls blood pressure (BP) for most people. C. Annual BP checks are needed to monitor treatment effectiveness. D. Hypertension is usually asymptomatic until target organ damage occurs

Correct Answer is D

Explanation

Hypertension, or high blood pressure, is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has already caused damage to target organs such as the heart, blood vessels, kidneys, or brain. It is crucial for the client to understand that even if they do not experience symptoms, untreated or poorly controlled hypertension can lead to serious complications, including heart disease, stroke, kidney problems, and more.

While dietary changes and increasing physical activity are important lifestyle modifications for managing hypertension, it is not accurate to state that most people can control their blood pressure through these measures alone. Hypertension is a complex condition influenced by multiple factors, and many individuals require additional interventions, such as medication, to effectively manage their blood pressure.

Annual blood pressure checks are indeed important to monitor the effectiveness of treatment and ensure that blood pressure remains within the target range. However, this information is secondary to the understanding that hypertension is typically asymptomatic until target organ damage occurs.

Recognizing the potential risks associated with untreated or uncontrolled hypertension can motivate the client to adhere to their treatment plan and make necessary lifestyle changes.

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The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

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Naxlex Comprehensive Predictor Exams

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four clients. Which nursing action can be delegated to the UAP?

Correct Answer is D

Explanation

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

Correct Answer is D

Explanation

The nurse is assessing a client with a hypertensive emergency. Which finding is most important to report to the health care provider?

The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

The nurse is providing discharge teaching to a client with venous insufficiency about compression stockings. Which information is essential for the nurse in the teaching plan?

The nurse and unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair?