A nurse is assessing a client suspected of having an abdominal aortic aneurysm (AAA). Which of the following physical assessment findings should the nurse prioritize?
Presence of a bruit over the abdominal area
Clubbing of the fingers
Decreased urinary output
Cyanosis of the extremities
The Correct Answer is A
A) Correct - The presence of a bruit (a turbulent blood flow sound) over the abdominal area is a priority finding when assessing for an AAA. It indicates possible turbulence caused by blood flow through the dilated artery and should be promptly reported for further evaluation.
B) Incorrect - Clubbing of the fingers is not a specific finding associated with AAA or peripheral vascular disorders. It may be related to respiratory or cardiac issues but is not relevant to this assessment.
C) Incorrect - Decreased urinary output may indicate kidney dysfunction or renal artery involvement in aneurysms, but it is not a priority finding compared to the presence of a bruit, which directly points to the aneurysm.
D) Incorrect - Cyanosis of the extremities may suggest compromised peripheral circulation, but it is not directly related to an AAA assessment. The presence of a bruit is more specific to aneurysm evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect - While monitoring urine output is essential, it is not the priority for a client post-abdominal aortic aneurysm repair. Other assessments take precedence to detect immediate complications.
B) Incorrect - Assisting with early ambulation is important for postoperative recovery, but it is not the priority when there might be a risk of complications from the surgery.
C) Correct - Assessing pedal pulses bilaterally is the priority nursing action post-abdominal aortic aneurysm repair. Diminished or absent pedal pulses could indicate compromised blood flow to the lower extremities, possibly due to a clot or embolism.
D) Incorrect - Monitoring blood glucose levels is relevant for some clients, but it is not the priority in this situation, unless the client has a specific history of diabetes or altered glucose levels that could impact their recovery.
Questions
Correct Answer is C
Explanation
A) Incorrect - While regular aerobic exercise is beneficial for overall vascular health, it may not specifically alleviate Raynaud's disease symptoms during cold weather.
B) Incorrect - Applying a heating pad to the affected areas is not the most effective intervention for managing Raynaud's disease symptoms. It may not fully address the underlying vascular constriction.
C) Correct - Avoiding exposure to cold temperatures is essential for managing Raynaud's disease symptoms. Cold temperatures can trigger vasospasm in affected areas, leading to color changes and discomfort.
D) Incorrect - Over-the-counter antihistamines are not a standard treatment for Raynaud's disease and may not directly alleviate symptoms related to cold weather exposure.
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