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 B
Explanation
A) Incorrect - Administering intravenous pain medication is important for the client's comfort but is not the priority in the immediate postoperative period after EVAR.
B) Correct - Monitoring for signs of graft occlusion is the priority in the immediate postoperative period after EVAR. Graft occlusion can lead to severe complications and requires prompt intervention.
C) Incorrect - Encouraging the client to cough and deep breathe is important for postoperative lung expansion, but it is not the priority when compared to monitoring for graft occlusion after EVAR.
D) Incorrect - Checking vital signs every 4 hours is a standard nursing intervention, but it is not the priority in the immediate postoperative period after EVAR, especially when graft occlusion may pose a more immediate threat.
Questions
Correct Answer is B
Explanation
A) Incorrect - Limiting daily water intake is not a lifestyle modification that directly impacts aneurysm prevention. Adequate hydration is generally encouraged for overall health.
B) Correct - Engaging in regular aerobic exercise is a lifestyle modification that can help prevent aneurysms and promote cardiovascular health. Exercise improves blood circulation and reduces the risk of various vascular disorders.
C) Incorrect - Consuming a high-fat diet is not recommended for aneurysm prevention. High-fat diets can contribute to atherosclerosis and other cardiovascular issues.
D) Incorrect - Smoking, even in small amounts, is a significant risk factor for aneurysms. Any amount of smoking should be strongly discouraged for individuals interested in preventing aneurysms and peripheral vascular disorders.
Questions
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