A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

An abdominal aortic aneurysm is commonly found in the suprarenal aorta.

An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery.

An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.

Abdominal aortic aneurysms might rupture if blood pressure is too low.

Answer and Explanation

The Correct Answer is C

A. An abdominal aortic aneurysm is commonly found in the suprarenal aorta: This statement is incorrect. Abdominal aortic aneurysms (AAAs) are most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal region.

B. An abdominal aortic aneurysm occurs as a result of a thickened wall of the abdominal artery: This statement is incorrect. An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm.

C. An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter: This statement is correct. An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition.

D. Abdominal aortic aneurysms might rupture if blood pressure is too low: This statement is incorrect. Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture.

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Correct Answer is C

Explanation

A. Tau protein: Tau protein is primarily associated with Alzheimer's disease and other tauopathies, not Lewy body dementia.

B. Neurofibrillary tangles: Neurofibrillary tangles are aggregates of hyperphosphorylated tau protein found in Alzheimer's disease, not typically in Lewy body dementia.

C. Alpha-synuclein protein: Lewy bodies, which are abnormal aggregates of alpha-synuclein protein, are a hallmark pathology of Lewy body dementia. These protein aggregates disrupt neuronal function and are responsible for the cognitive, motor, and emotional symptoms seen in Lewy body dementia.

D. Beta-amyloid protein: Beta-amyloid protein is primarily associated with Alzheimer's disease, not Lewy body dementia. It forms plaques in the brain, which contribute to neurodegeneration and cognitive decline in Alzheimer's disease.

A. Lower extremities edematous with decreased pulses and cool to the touch B. Pain, pallor, and paresthesia in the foot C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema D. Presence of an open wound near the ankle with serous drainage and pruritus

Correct Answer is B

Explanation

A. Lower extremities edematous with decreased pulses and cool to the touch While this finding suggests impaired circulation associated with peripheral artery disease, it does not indicate an immediate need for intervention. However, it requires timely assessment and intervention to prevent further complications.

B. Pain, pallor, and paresthesia in the foot This finding indicates critical limb ischemia, which is a severe complication of peripheral artery disease requiring immediate intervention. Pain, pallor (pale color), and paresthesia (abnormal sensations like tingling or numbness) suggest inadequate blood flow to the affected limb, putting the client at risk for tissue damage and limb loss if not promptly addressed.

C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema These findings are suggestive of cardiac issues such as heart failure rather than immediate complications of peripheral artery disease. While they require attention, they do not signify an urgent need for intervention specific to peripheral artery disease.

D. Presence of an open wound near the ankle with serous drainage and pruritus While an open wound warrants assessment and appropriate wound care, it does not indicate an immediate need for intervention unless there are signs of infection or severe tissue damage. In this scenario, the presentation of pain, pallor, and paresthesia indicates a more urgent need for intervention to prevent tissue necrosis and limb loss.

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A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA). Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

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