Exhibits
The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.
Indigestion
Tiredness
Extremity pulse 2+
Pain level in abdomen and back
Pulsatile mass
Liquid diarrhea
Abdominal bruit
Correct Answer : D,E,G
Rationale:
A. Indigestion: Although indigestion may mimic early symptoms of abdominal pathology, the client has not explicitly described heartburn or acid-related symptoms. It is a non-specific complaint and less concerning than the signs suggesting a vascular emergency.
B. Tiredness: Fatigue in older adults is often non-specific and may be related to underlying chronic conditions like atrial fibrillation or age-related decline. However, it is not as urgent or directly life-threatening as other findings suggesting vascular compromise.
C. Extremity pulse 2+: Pulses rated 2+ are considered normal and symmetric, indicating that peripheral perfusion is currently intact. This finding is stable and does not require immediate follow-up in the context of this clinical picture.
D. Pain level in abdomen and back: Severe, gnawing abdominal and back pain raises concern for a potentially rupturing or expanding abdominal aortic aneurysm (AAA). This symptom needs immediate evaluation due to the risk of hemodynamic collapse.
E. Pulsatile mass: A pulsatile abdominal mass is a hallmark sign of an AAA. When found on physical exam, especially with accompanying pain, it indicates a life-threatening condition that can lead to sudden rupture and requires emergency imaging and surgical consultation.
F. Liquid diarrhea: Although a change in bowel pattern may be relevant, the client reports that this is not unusual for him. Diarrhea is not immediately threatening in this context and is unlikely to be the primary cause of the abdominal symptoms.
G. Abdominal bruit: A bruit over a pulsatile abdominal mass indicates turbulent blood flow, further supporting suspicion of aortic aneurysm. This is a critical sign that suggests vascular pathology and requires urgent diagnostic confirmation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Insert 30 mL air bolus while auscultating over abdomen: Introducing air into a misplaced NG tube in the chest cavity may worsen injury or cause a pneumothorax or tension pneumothorax, especially if the tube has entered the pleural space or lung.
B. Remove the NG tube: Chest x-ray confirms malposition in the chest cavity, likely the pleural space or lung. The tube must be removed immediately to prevent further trauma or air/fluid accumulation.
C. Clamp the NG tube: Clamping prevents the entry or exit of air and fluids, minimizing risk of complications like aspiration or worsening pneumothorax while awaiting removal or re-evaluation.
D. Auscultate chest and abdomen following removal of NG tube: Assessing for abnormal breath or bowel sounds post-removal helps detect potential complications such as pneumothorax, hemothorax, or abdominal injury.
E. Connect the NG tube to low wall suction: Connecting a malpositioned NG tube to suction could draw air or fluids from the pleural space or lung, worsening the trauma or leading to complications such as lung collapse.
Correct Answer is B
Explanation
Rationale:
A. Self-description of pain: Pain assessment is important in general care but is not directly related to assessing for obstructive sleep apnea. OSAS is more concerned with sleep patterns, airway obstruction, and associated risk factors like weight and anatomy rather than pain.
B. Body mass index: BMI is a key factor in determining OSAS risk. Obesity, especially central adiposity, contributes to pharyngeal narrowing and increased airway resistance during sleep. A high BMI is one of the most significant predictors of obstructive sleep apnea.
C. Level of consciousness: While decreased alertness can result from sleep deprivation caused by OSAS, it is a non-specific finding. It may support further evaluation but does not directly assess the risk for OSAS or its underlying causes.
D. Breath sounds: Although breath sounds can reveal lung pathology, they typically remain normal in OSAS unless another respiratory condition is present. They are not the most important assessment for evaluating sleep-disordered breathing risk.
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