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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The inability to move the left arm and leg suggests a neurological deficit, which is a significant finding that requires immediate attention. It could indicate a potential stroke or another neurological emergency that requires prompt evaluation and intervention. The health care provider needs to be notified immediately so that appropriate diagnostic tests and interventions can be initiated.

Tremors in the fingers when extending the arms can be a sign of tremor disorders or medication side effects but may not warrant immediate intervention.

Atrial fibrillation is a cardiac arrhythmia that requires monitoring and management but may not be directly related to the acute neurological issue.

The headache reported by the patient, although significant, is subjective and may be related to the hypertensive emergency or other factors but does not require immediate intervention compared to the potential neurological deficit.

A. Assess the client's use of over-the-counter dietary supplements. B. Implement interventions relevant to arterial narrowing C. Encourage the client to increase intake of foods high in vitamin K D. Adjust the client's activity level to accommodate decreased coronary output.

Correct Answer is B

Explanation

The nurse should best follow up the assessment ﬁnding of an ankle-brachial index (ABI) of 0.40 in the right leg by implementing interventions relevant to arterial narrowing.

An ankle-brachial index is a non-invasive test used to assess peripheral arterial disease (PAD). An ABI value below 0.90 indicates signiﬁcant arterial narrowing and impaired blood ﬂow to the lower extremities. An ABI of 0.40 suggests severe arterial narrowing, which puts the client at risk for reduced perfusion and potential complications such as tissue ischemia, ulceration, and gangrene.

Implementing interventions relevant to arterial narrowing is crucial in this case. These interventions may include:

Collaborating with the healthcare provider to develop a treatment plan: This may involve prescribing medications to improve blood ﬂow, such as antiplatelet agents or vasodilators.
Encouraging lifestyle modiﬁcations: This can include smoking cessation, regular exercise, and maintaining a healthy diet low in saturated fats and high in fruits and vegetables.
Promoting optimal cardiovascular health: This can involve managing other risk factors for arterial narrowing, such as hypertension, diabetes, and high cholesterol levels.
Educating the client about the signs and symptoms of PAD: This includes teaching them to monitor for changes in skin color, temperature, and sensation in the affected limb, as well as the importance of seeking prompt medical attention if these changes occur.

Let's review the other options:

Assessing the client's use of over-the-counter dietary supplements: While it is important to assess for potential interactions between medications and dietary supplements, this would not be the immediate follow-up action for a severely reduced ABI.

Encouraging the client to increase intake of foods high in vitamin K: While maintaining a balanced diet is important for overall health, increasing vitamin K intake is not speciﬁcally indicated for addressing arterial narrowing or improving the ABI.

Adjusting the client's activity level to accommodate decreased coronary output:

Coronary output refers to blood ﬂow to the heart muscle. Arterial narrowing in the leg does not directly affect coronary output. However, it is important to encourage appropriate physical activity for the client based on their overall cardiovascular health and exercise tolerance.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Correct Answer is C

Explanation

While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment ﬁnding?

Correct Answer is B

Explanation

The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

The nurse is caring for a client with hypertension who is on alpha blockers. The nurse is concerned about postural hypotension. Which information should the nurse include in the teaching plan?

The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

The nurse is providing discharge education to a client with hypertension. Which essential information should the nurse include in the teaching plan?

The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

A nurse is teaching a hypertensive client who is taking hydrochlorothiazide. What client statement indicates understanding about hydrochlorothiazide?

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?