A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse identify as a clinical emergency?
Bounding pedal pulses
Sudden lower-back pain
Flushed, dry skin
Absence of a thrill
The Correct Answer is B
Rationale:
A. Bounding pedal pulses: Bounding pulses may be present in the early stages of an aneurysm due to increased blood flow or pressure, but they are not an immediate sign of rupture or clinical emergency. They do not necessarily indicate instability.
B. Sudden lower-back pain: This is a classic sign of impending or actual rupture of an abdominal aortic aneurysm (AAA). It indicates internal bleeding or pressure from the expanding aneurysm and demands immediate emergency evaluation and intervention.
C. Flushed, dry skin: Flushed, dry skin can result from a variety of causes such as fever or dehydration, but it is not specific to an abdominal aortic aneurysm or its rupture and is not considered an emergency sign in this context.
D. Absence of a thrill: A thrill is a vibration felt over turbulent blood flow and may or may not be present with an aneurysm. Its absence is not considered an emergency finding and does not reliably indicate aneurysm rupture or progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Maintain the head of the client's bed at a 10° angle: A 10° angle is too low to effectively promote venous drainage from the brain. To reduce intracranial pressure (ICP), the head of the bed should generally be elevated to 30–45° to improve cerebral venous outflow.
B. Suction the client's airway every hour: Frequent suctioning increases intrathoracic pressure and can stimulate the vagus nerve, both of which may raise ICP. Suctioning should be done only when clinically indicated and using minimal duration and pressure.
C. Reposition the client by using the log rolling technique: Log rolling maintains spinal alignment and minimizes abrupt head or neck movement, which can increase ICP. This technique is especially important in patients with brain or spinal injuries to prevent sudden shifts in pressure.
D. Use a pillow to flex the client's neck: Neck flexion can obstruct jugular venous outflow, leading to increased ICP. The head and neck should remain in a neutral, midline position to facilitate venous drainage from the brain.
Correct Answer is B
Explanation
Rationale:
A. Anthrax: Anthrax is not spread from person to person. It is typically transmitted through direct contact with spores via inhalation, ingestion, or skin exposure. Inhalation anthrax is the most deadly form, but it remains non-communicable between individuals.
B. Smallpox: Smallpox is highly communicable and spreads through respiratory droplets during close contact. It can also be transmitted via contaminated objects such as bedding or clothing, making it a serious bioterrorism threat due to its ease of transmission.
C. Tularemia: Tularemia is not communicable from person to person. It is usually transmitted through insect bites, direct contact with infected animals, or inhalation of contaminated aerosols. Human-to-human transmission has not been documented.
D. Clostridium botulinum: Botulism results from a neurotoxin produced by Clostridium botulinum and is not spread from person to person. Transmission occurs through ingestion of contaminated food, wound infection, or rarely, inhalation of the toxin in bioterrorism scenarios.
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