The nurse is admitting a client with Abdominal aortic aneurysm. Which assessment data would support the diagnosis?
Shortness of breath.
Abdominal bruit.
Ripping abdominal pain.
Decreased urinary output.
The Correct Answer is B
A bruit is a sound that can be heard with a stethoscope when blood flows through a narrowed or damaged artery. An abdominal bruit may indicate an abdominal aortic aneurysm (AAA), which is a bulge or swelling in the main blood vessel that runs from the heart down through the chest and tummy.
Shortness of breath is a common symptom of many conditions, but it is not specific to AAA. It can be caused by heart or lung problems, anemia, anxiety, lack of exercise, obesity, and many other factors. Shortness of breath may occur with a ruptured AAA, but it is not a reliable sign of an intact AAA.
Ripping abdominal pain is a severe and sudden pain that may indicate a ruptured AAA, which is a life-threatening situation that requires immediate medical attention. However, an intact AAA usually does not cause any pain or discomfort. Therefore, ripping abdominal pain is not a good indicator of an AAA diagnosis.
Decreased urinary output is a sign of reduced kidney function, which can have many causes such as dehydration, kidney failure, urinary tract obstruction, or medication side effects. Decreased urinary output is not directly related to AAA, although it may occur as a complication of a ruptured AAA or surgery to repair an AAA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The information that the nurse should include in the discharge teaching for the client who is three days post-operative abdominal aortic aneurysm repair is as follows:
Notify the healthcare provider (HCP) of any redness or irritation of the incision: This is important because redness or irritation can be signs of infection or other complications at the surgical site. Prompt reporting allows for early intervention and management.
Do not lift anything more than 20 pounds: Following abdominal aortic aneurysm repair, it is crucial to avoid heavy lifting or straining as it can put excessive pressure on the surgical site and potentially lead to complications such as incisional hernia. Restricting lifting to no more than 20 pounds helps to protect the incision and promote proper healing.
Inform the client that there may be pain not relieved with pain medication: Pain management is an essential aspect of post-operative care. However, it is important for the client to understand that complete relief of pain may not always be achievable with pain medication alone. They should be aware that mild to moderate discomfort may persist during the healing process, but severe or worsening pain should be reported to the healthcare provider.
Stress the importance of having daily bowel movements: After abdominal surgery, it is common for bowel movements to be delayed due to factors such as anesthesia, reduced activity, and pain medication. However, it is crucial for the client to maintain regular bowel movements to prevent constipation and potential complications such as bowel obstruction. The nurse should provide guidance on strategies to promote regular bowel function, such as staying hydrated, eating a balanced diet rich in fiber, and using stool softeners or gentle laxatives as directed by the healthcare provider.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.