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
Absent bilateral pedal pulses indicate a potential vascular complication, such as impaired circulation or blood flow to the lower extremities. It may suggest compromised perfusion and could be a sign of arterial occlusion or thrombosis, which requires immediate intervention. The nurse should notify the healthcare provider promptly to assess the client's condition and initiate appropriate interventions to restore circulation to the lower extremities.
While complaints of pain at the site of the incision are significant, post-operative pain is expected after abdominal surgery. The nurse should assess the pain and provide appropriate pain management interventions, but it may not require immediate intervention unless the pain is severe or accompanied by other concerning symptoms.
A distended, tender abdomen could indicate various post-operative complications, such as bowel obstruction or peritonitis. Although it should be evaluated and reported to the healthcare provider, it may not require immediate intervention unless the client's condition deteriorates or other signs of a surgical emergency are present.
An elevated temperature of 100°F (37.8°C) alone, without other signs of infection or systemic complications, may not necessarily require immediate intervention. It could be a normal response to surgery or a mild post-operative infection. The nurse should monitor the client's temperature and assess for other signs of infection, and if necessary, report it to the healthcare provider for further evaluation.
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.
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