The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse?
Measurement of abdominal girth
Auscultation of any area in the abdomen
Palpation of the abdominal midline area
Observation of abdominal wall movement
The Correct Answer is C
A. Measuring abdominal girth can help monitor the aneurysm.
B. Auscultation is safe and may reveal bruits associated with aneurysms.
C. Palpation of the abdominal midline area is dangerous and can risk rupturing the aneurysm, requiring further education.
D. Observation is non-invasive and safe.
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Related Questions
Correct Answer is D
Explanation
A. Multiple abdominal drains increase infection risk.
B. Cellulitis poses a high risk of infection.
C. Viral pneumonia is contagious and poses a high infection risk.
D. Chronic heart failure does not pose an infection risk, making this the safest roommate choice.
Correct Answer is B
Explanation
A. Blurred vision is not a typical symptom of left-sided heart failure.
B. Difficulty breathing while performing activities, such as climbing stairs, is a classic symptom of left-sided heart failure due to pulmonary congestion.
C. Increased water intake is not directly indicative of left-sided heart failure.
D. Nocturia can occur in heart failure, but it is less specific than dyspnea on exertion.
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