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Exhibits

The nurse evaluates the client's findings and test results. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

The nurse recognizes that the client is most at risk for aneurysm

. The risk for this complication is highest in individuals with a history of.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Rupture: Aneurysm rupture is the most serious and immediate complication of an abdominal aortic aneurysm (AAA). The client’s gnawing back and abdominal pain, along with a pulsatile abdominal mass and bruit, suggest that the aneurysm is unstable.
  • Hypertension: Chronic high blood pressure exerts continuous force on arterial walls, weakening the aortic structure and promoting aneurysm formation and progression. It significantly increases the likelihood of rupture once an aneurysm is present.

Rationale for Incorrect Choices:

  • Dissection: Dissection involves a tear in the intimal layer of the artery, creating a false lumen. Although serious, it is more commonly associated with thoracic aortic aneurysms rather than abdominal ones. The client's symptoms and findings are more consistent with rupture.
  • Occlusion: Aneurysm-related occlusion refers to blockage of blood flow, which is less common in abdominal aneurysms. The client’s peripheral pulses are normal (2+), indicating adequate distal perfusion. There’s no sign of limb ischemia or thrombotic complications.
  • Smoking: Smoking is a known risk factor for developing aneurysms but is not the most direct or strongest predictor of rupture. Its role is more associated with aneurysm formation and progression. Hypertension more specifically correlates with increased rupture risk.
  • Hyperlipidemia: High lipid levels contribute to atherosclerosis, which can lead to aneurysm development over time. However, like smoking, it is not as strongly associated with aneurysm rupture as hypertension.


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Related Questions

Correct Answer is ["B","D","E"]

Explanation

Rationale:
A. Assess for breath with a fruity odor: This is more indicative of diabetic ketoacidosis (DKA), not HHS. HHS does not usually produce ketones or fruity-smelling breath, so it is not a priority assessment for this condition.

B. Titrate an insulin infusion to maintain a low serum glucose level: Maintaining glucose control through insulin infusion is critical in preventing HHS, as the syndrome is driven by severe hyperglycemia without ketosis.

C. Monitor for elevated temperature and administer PRN antipyretics: While fever management is important for burn care, it does not directly prevent HHS, which is primarily a result of fluid imbalance and hyperglycemia.

D. Monitor serum electrolyte levels and report any abnormal values: Electrolyte disturbances are common in HHS due to dehydration and osmotic diuresis. Prompt correction is essential to prevent complications.

E. Maintain large bore IV patency for aggressive fluid resuscitation: Massive fluid loss from burns and hyperglycemia requires aggressive IV fluid replacement to prevent dehydration and hemoconcentration, both of which contribute to HHS.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Choices

  • Neglect: The client presents with signs of poor hygiene, untreated pressure injuries, confinement to bed without a clear medical reason, and a reduction in social interaction and autonomy. These factors collectively indicate neglect, which is the failure of a caregiver to meet the basic physical, emotional, and social needs of a dependent adult.
  • Adult Protective Services: Adult Protective Services is the appropriate authority to report suspected abuse or neglect of older adults living in private homes. As a mandated reporter, the nurse is legally required to report suspected elder mistreatment to APS to initiate an investigation and protect the client.

Rationale for Incorrect Choices

  • Sexual abuse: There are no indicators such as bruising in private areas, fear of the caregiver, or behavioral cues that might suggest sexual trauma. The case centers on physical neglect, not sexual abuse.
  • Financial exploitation: The client has not reported any unauthorized financial activity, and there is no evidence of the caregiver misusing or controlling the client’s finances. This makes financial exploitation an unlikely concern.
  • Long Term Care Program: This agency oversees long-term care facilities like nursing homes. Since the client resides in a private home, the situation falls outside the jurisdiction of this program.
  • State Department of Health: The Department of Health primarily monitors healthcare providers and facilities, not private caregiving situations. Therefore, it is not the correct agency to report suspected elder abuse in this context.

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