The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
White blood cell count and pulse rate.
Hematocrit and blood pressure.
Calcium level and skin condition.
Serum amylase and level of consciousness.
The Correct Answer is B
Choice A reason: White blood cell count and pulse rate are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. White blood cell count is a measure of the immune system activity, and it may be elevated in cases of infection or inflammation, but it is not specific to AAA. Pulse rate is a measure of the heart rate, and it may be increased in cases of anxiety, pain, or shock, but it is not indicative of AAA.
Choice B reason: Hematocrit and blood pressure are the most important information about the client that the nurse should tell the healthcare provider, because they are directly related to the AAA and the low back pain. Hematocrit is a measure of the percentage of red blood cells in the blood, and it may be decreased in cases of bleeding or anemia, which can occur if the AAA ruptures or leaks. Blood pressure is a measure of the force of the blood against the walls of the arteries, and it may be increased in cases of hypertension or stress, which can worsen the AAA or cause it to rupture. The nurse should monitor the client's hematocrit and blood pressure closely and report any changes to the healthcare provider.
Choice C reason: Calcium level and skin condition are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Calcium level is a measure of the amount of calcium in the blood, and it may be abnormal in cases of bone disorders, kidney disorders, or parathyroid disorders, but it is not relevant to AAA. Skin condition is a general term that can describe the appearance, texture, color, or temperature of the skin, and it may be altered in cases of infection, allergy, or injury, but it is not specific to AAA.
Choice D reason: Serum amylase and level of consciousness are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Serum amylase is a measure of the amount of amylase, an enzyme that digests starch, in the blood, and it may be elevated in cases of pancreatitis, gallstones, or intestinal obstruction, but it is not associated with AAA. Level of consciousness is a measure of the client's mental status, alertness, and responsiveness, and it may be impaired in cases of brain injury, stroke, or coma, but it is not indicative of AAA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Using a bed cradle to hold the covers off feet is not a good option for a client with DM and right hemiplegia, because it can increase the risk of injury and infection to the feet. The client may have reduced sensation and circulation in the feet due to diabetic neuropathy and peripheral vascular disease, which can make the feet more prone to ulcers, gangrene, and amputation. The client should keep the feet covered and protected from pressure and trauma.
Choice B reason: Providing a warming pad (Aqua-pad or K-pad) to feet is the best option for a client with DM and right hemiplegia, because it can help improve the blood flow and comfort to the feet. The warming pad is a device that circulates warm water or air through a pad that is placed on the skin. The nurse should monitor the temperature and duration of the warming pad, and check the skin for signs of burns or blisters.
Choice C reason: Placing warm blankets next to the client’s feet is not a reliable option for a client with DM and right hemiplegia, because it may not provide enough warmth and may slip off during the night. The client may not be able to adjust the blankets due to the hemiplegia, which can affect the movement and strength of the right side of the body. The client may also have difficulty feeling the blankets due to the neuropathy.
Choice D reason: Medicating the client with a prescribed sedative is not a suitable option for a client with DM and right hemiplegia, because it does not address the underlying cause of the cool feet, and may have adverse effects on the client’s condition. The sedative may interact with the client’s other medications, such as insulin or oral hypoglycemics, and cause hypoglycemia, which can worsen the stroke recovery. The sedative may also cause respiratory depression, which can affect the oxygen delivery to the brain and the feet.
Correct Answer is A
Explanation
Choice A reason: Beginning a weight loss program can help reduce the severity of OSA, which is a condition that causes repeated episodes of breathing cessation during sleep due to upper airway obstruction. Excess weight can contribute to OSA by increasing the fat deposits around the neck and throat, which can narrow the airway and make it more prone to collapse. Losing weight can help improve the airflow and reduce the need for CPAP therapy.
Choice B reason: Drinking 1 to 2 glasses of wine at bedtime can worsen OSA, which is a condition that requires adequate oxygenation and ventilation during sleep. Alcohol can relax the muscles of the throat and tongue, which can increase the risk of airway obstruction and apnea. Alcohol can also disrupt the sleep cycle and quality, which can affect the overall health and well-being of the client.
Choice C reason: Taking sedatives prior to sleep can also worsen OSA, which is a condition that requires alertness and arousal during sleep to resume breathing after an apneic episode. Sedatives can depress the central nervous system and the respiratory drive, which can reduce the responsiveness and the ability to overcome the airway obstruction. Sedatives can also have adverse effects, such as drowsiness, confusion, and dependency.
Choice D reason: Sleeping with the head of the bed flat can also worsen OSA, which is a condition that requires optimal positioning and alignment during sleep to prevent the airway obstruction. Sleeping with the head of the bed flat can cause the tongue and the soft palate to fall back and block the airway, especially when lying on the back. Sleeping with the head of the bed elevated can help open the airway and reduce the snoring and the apnea.
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