The nurse admits a patient with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that the aneurysm has ruptured?

Rapid onset of shortness of breath and hemoptysis

Gradually increasing sub sternal chest pain and diaphoresis

Sudden, patchy blue mottling on the feet and toes and pain at rest

Sudden, severe low back pain and bruising along the flank area

Answer and Explanation

The Correct Answer is D

A. Rapid onset of shortness of breath and hemoptysis: These symptoms suggest a pulmonary etiology, such as pulmonary embolism or pneumonia, rather than an abdominal aortic aneurysm (AAA). They do not indicate aneurysm rupture.

B. Gradually increasing substernal chest pain and diaphoresis: This presentation is more typical of acute coronary syndrome or myocardial infarction. While cardiac events can coexist, these findings do not reflect the classic signs of AAA rupture.

C. Sudden, patchy blue mottling on the feet and toes and pain at rest: These symptoms suggest peripheral arterial embolism or severe peripheral vascular disease. Although vascular in origin, they are not indicative of a ruptured AAA.

D. Sudden, severe low back pain and bruising along the flank area: Ruptured abdominal aortic aneurysms classically present with acute, severe abdominal or low back pain, hypotension, and retroperitoneal bleeding, which can manifest as flank ecchymosis (Grey-Turner sign). These findings are hallmarks of AAA rupture and require immediate surgical intervention.

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Correct Answer is D

Explanation

A. Determine disability using the Glasgow Coma Scale: Assessing neurologic status with the Glasgow Coma Scale is important, but it is secondary to ensuring airway, breathing, and circulation. Immediate airway management takes priority in an unconscious patient with hypoventilation.

B. Obtain laboratory tests: Laboratory tests help identify the toxic agent and guide treatment, but collecting labs does not address the immediate life-threatening risk of hypoxia from inadequate ventilation.

C. Administer a central nervous system stimulant: Giving a CNS stimulant is not a safe or standard intervention for sedative overdose. Stimulants do not reverse respiratory depression and could worsen cardiovascular instability.

D. Maintain a patent airway: The patient’s respiratory rate is critically low (10 breaths/min), indicating hypoventilation and risk of hypoxia. Securing and maintaining a patent airway is the highest priority to ensure oxygenation and prevent respiratory arrest, following the ABCs of emergency care.

A. Inspiratory crackles B. Bilateral wheezing C. Increased respiratory rate D. Intercostal retractions

Correct Answer is C

Explanation

A. Inspiratory crackles: Crackles typically appear later in respiratory distress syndrome (RDS) due to alveolar collapse and fluid accumulation. Early in the syndrome, the alveoli are still partially functional, so crackles may not yet be present. Relying on this finding could delay recognition of the initial compromise.

B. Bilateral wheezing: Wheezing results from bronchospasm or airway obstruction and is more characteristic of conditions like asthma or COPD exacerbations. It is not an early sign of RDS, which primarily involves alveolar collapse, decreased surfactant, and impaired gas exchange rather than bronchial constriction.

C. Increased respiratory rate: Tachypnea is an early compensatory response to hypoxemia and carbon dioxide retention in RDS. The body attempts to maintain oxygenation and ventilation by increasing the respiratory rate before overt signs such as crackles or retractions appear, making it a key early indicator.

D. Intercostal retractions: Retractions indicate increased work of breathing and usually occur later in the progression of respiratory distress. They reflect significant respiratory muscle fatigue and impending respiratory failure rather than an initial compensatory change.

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The nurse admits a patient with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that the aneurysm has ruptured?

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