A nurse is caring for a client with a suspected aneurysm. Which of the following assessments should the nurse prioritize to monitor for potential rupture?
Pain level assessment
Blood pressure measurement
Respiratory rate evaluation
Urinary output monitoring
The Correct Answer is A
A) Correct - Pain level assessment is essential in monitoring for aneurysm rupture because sudden, severe, and persistent pain is a common manifestation. It could indicate that the aneurysm is leaking or has ruptured, requiring immediate medical attention.
B) Incorrect - While blood pressure measurement is important in managing aneurysm, it may not be the best indicator of an imminent rupture. Some aneurysms are asymptomatic until they rupture.
C) Incorrect - Respiratory rate evaluation is not a primary assessment for aneurysm rupture. Although respiratory distress may occur due to pain or compromised blood flow after rupture, it is not the initial priority.
D) Incorrect - While monitoring urinary output is important in various clinical settings, it is not a priority assessment for aneurysm rupture. There are more specific symptoms related to aneurysm rupture that the nurse should focus on.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect - A high-stress lifestyle can contribute to various health issues, but it is not a genetic risk factor for aneurysms. Stress may exacerbate hypertension, which is a known risk factor.
B) Incorrect - Smoking history is a behavioral risk factor rather than a genetic one. Smoking damages blood vessels and increases the risk of aneurysms through direct and indirect mechanisms.
C) Correct - A positive family history of aneurysms is a genetic risk factor. Having a first-degree relative with a history of an aneurysm increases an individual's risk of developing one.
D) Incorrect - A sedentary lifestyle is a behavioral risk factor for aneurysms, not a genetic one. Lack of physical activity can contribute to hypertension and other risk factors.
Correct Answer is B
Explanation
A) Incorrect - While surgical repair is an option for larger or symptomatic AAAs, it is not the only treatment option for small, asymptomatic AAAs.
B) Correct - For small asymptomatic AAAs, close monitoring of the aneurysm size and growth is a common approach. The size and rate of growth will determine the appropriate treatment plan.
C) Incorrect - Blood-thinning medications are not the standard treatment for small asymptomatic AAAs. These medications are generally used for other cardiovascular conditions.
D) Incorrect - Endovascular repair may be an option for some AAAs, but it is not the best treatment for all cases, especially small, asymptomatic ones. The appropriate treatment plan will depend on the client's specific circumstances.
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