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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Maintaining a 2 gram-sodium (salt) diet is an important aspect of managing hypertension. High sodium intake can contribute to elevated blood pressure. Therefore, reducing sodium intake is recommended to help control blood pressure levels. The nurse should provide guidance on reading food labels, avoiding high-sodium processed foods, and incorporating a diet rich in fruits, vegetables, and whole grains.

The other options listed are not appropriate or beneficial for managing hypertension:

Maintaining a low-potassium diet: Potassium is an essential mineral that helps regulate blood pressure. While specific potassium restrictions may be necessary for some individuals with certain medical conditions, most people with hypertension do not need to limit their potassium intake. In fact, a balanced diet with adequate potassium is generally recommended.

Skipping a medication dose if dizziness occurs: It is not advisable to skip medication doses without consulting a healthcare provider. Hypertension medications are prescribed to help control blood pressure, and missing doses can lead to uncontrolled hypertension and potential complications. If the client experiences dizziness or other side effects from the medication, they should consult their healthcare provider for appropriate management.

Drinking three glasses of wine a day: Excessive alcohol consumption can contribute to elevated blood pressure. The recommended alcohol intake for individuals with hypertension is moderate or limited to moderate levels, which typically means no more than one drink per day for women and two drinks per day for men. Drinking excessive amounts of wine or any alcoholic beverage can negatively affect blood pressure control.

A. Assess pulse of affected extremity every 15 minutes at ﬁrst. B. Palpate the affected leg for pain during every assessment C. Assess the client for signs and symptoms of compartment syndrome every 2 hours. D. Perform Doppler evaluation once daily.

Correct Answer is ["A","B","C","D"]

Explanation

Assess pulse of the affected extremity every 15 minutes at ﬁrst: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood ﬂow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.

Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood ﬂow or other complications that require immediate attention.

Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.

Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood ﬂow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not suﬃcient if there are concerns regarding blood ﬂow or graft viability.

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The nurse is admitting a client with Abdominal aortic aneurysm. Which assessment data would support the diagnosis?

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Naxlex Comprehensive Predictor Exams

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