The nurse recognizes that the client is most at risk for aneurysm
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Rationale for Correct Choices
• Rupture: The client’s 8.6 cm abdominal aortic aneurysm (AAA) represents a critical dilation far exceeding the typical surgical threshold of 5.5 cm. At this size, the risk of rupture is extremely high because the aortic wall tension increases exponentially as diameter enlarges. The client’s escalating pain intensity in the back and abdomen also signals potential aneurysmal wall weakening or impending rupture.
• Hypertension: Chronic hypertension exerts continuous high pressure on arterial walls, contributing to both aneurysm formation and rupture risk. Elevated systolic pressures accelerate vessel wall degeneration and increase tension on the dilated aorta, especially in elderly patients with atherosclerosis. This client’s medical history of long-term hypertension and vascular disease significantly elevates his rupture risk.
Rationale for Incorrect Choices
• Occlusion: While aneurysms can rarely thrombose and obstruct blood flow, occlusion is not the predominant or immediate risk. The client’s symptoms are more consistent with wall expansion rather than clot formation or arterial blockage.
• Dissection: Aortic dissection involves a tear in the intimal layer allowing blood to separate vessel wall layers, typically presenting with sudden, sharp, tearing chest or back pain. This client’s gradual onset of gnawing pain and imaging showing aneurysmal dilation (not a dissection flap) indicate a degenerative aneurysm rather than a dissection.
• Smoking: Although smoking contributes to aneurysm development by weakening vascular walls through oxidative damage, it is not the highest risk factor for rupture. The acute rupture risk correlates more closely with hypertension-driven wall stress than with smoking history.
• Hyperlipidemia: Hyperlipidemia promotes atherosclerosis, which predisposes to aneurysm formation, but it is less directly linked to aneurysm rupture. The immediate rupture risk arises from hemodynamic strain caused by poorly controlled blood pressure rather than lipid levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Rationale:
A. Place in lateral Trendelenburg position: This position lowers the head below the heart, which can increase cerebral blood volume and further raise intracranial pressure. Clients with head injuries should instead be maintained in a neutral head position with the head of the bed elevated about 30 degrees to promote venous drainage.
B. Insert a second large bore IV catheter: The client’s neurological deterioration suggests possible intracranial bleeding or herniation. Inserting another IV line ensures rapid access for fluids, osmotic diuretics, or emergency medications if the client’s condition worsens.
C. Schedule a repeat CT scan: New-onset anisocoria (unequal pupils) and vomiting indicate potential brain swelling or expanding hematoma. An urgent repeat CT scan helps identify evolving intracranial pathology that may require surgical intervention.
D. Apply artificial tear drops to left eye: A dilated, nonreactive pupil may indicate cranial nerve III involvement, impairing eyelid closure and corneal protection. Artificial tears prevent corneal drying and injury while further neurological evaluation is conducted.
E. Repeat Glasgow coma assessment: Ongoing monitoring of the Glasgow Coma Scale allows for early detection of further neurological decline. Frequent reassessments help guide interventions and communicate changes promptly to the healthcare provider.
Correct Answer is B
Explanation
Rationale:
A. Suction oral cavity frequently to maintain a patent airway: Frequent suctioning increases intrathoracic pressure and can transiently elevate intracranial pressure due to stimulation of the vagus nerve and coughing. Suctioning should be performed only when necessary.
B. Keep client’s head in a midline position with head raised 30°: Maintaining the head midline and elevating it to about 30 degrees promotes optimal venous drainage from the brain and prevents obstruction of jugular venous outflow. This position effectively stabilizes or lowers intracranial pressure while maintaining cerebral perfusion.
C. Extend neck with a soft collar placed at base of client’s skull: Neck extension can impede venous return from the brain, leading to increased intracranial pressure. Proper alignment, rather than extension or flexion, is critical to allow unobstructed cerebral venous drainage.
D. Turn entire body from side to side at least every 2 hours: Repositioning is important for preventing pressure injuries, but abrupt or improper turning can cause surges in intracranial pressure. Movements should be slow and coordinated, with careful head and neck alignment.
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