Nokea
Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)?
- A. Shortness of breath.
- B. Abdominal bruit.
- C. Ripping abdominal pain.
- D. Decreased urinary output.
Correct Answer: B
Rationale: An abdominal bruit (B) is a key sign of AAA due to turbulent flow. Shortness of breath (A) is nonspecific, ripping pain (C) suggests dissection, and low urine output (D) is a complication, not diagnostic.
You may also like to solve these questions
The client with coronary artery disease asks why they need a stress test. What is the best response?
- A. It checks for blood clots in your heart.
- B. It evaluates how your heart works under stress.
- C. It measures your cholesterol levels.
- D. It monitors your blood pressure.
Correct Answer: B
Rationale: A stress test assesses heart function during physical stress to detect ischemia or blockages.
The nurse is assessing a client with mitral regurgitation. Which finding is expected?
- A. High-pitched holosystolic murmur
- B. Bradycardia
- C. Clear lung sounds
- D. Hypotension
Correct Answer: A
Rationale: Mitral regurgitation causes a high-pitched holosystolic murmur due to blood flowing back into the left atrium.
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement?
- A. Praise the client for having a normal cholesterol level.
- B. Explain that the client needs to lower the cholesterol level.
- C. Discuss dietary changes that could help increase the level.
- D. Allow the client to ventilate feelings about the blood test result.
Correct Answer: B
Rationale: Cholesterol 240 mg/dL (B) is high (>200 is abnormal), requiring education to lower it. Praising (A) is incorrect, increasing (C) is harmful, and venting (D) is secondary.
Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair?
- A. Absent bilateral pedal pulses.
- B. Complaints of pain at the site of the incision.
- C. Distended, tender abdomen.
- D. An elevated temperature of 100°F.
Correct Answer: A
Rationale: Absent pedal pulses (A) suggest graft occlusion, a surgical emergency. Incisional pain (B), distension (C), and low-grade fever (D) are expected or less urgent.