The nurse is admitting a client with Abdominal aortic aneurysm. Which assessment data would support the diagnosis?
Shortness of breath.
Abdominal bruit.
Ripping abdominal pain.
Decreased urinary output.
The Correct Answer is B
A bruit is a sound that can be heard with a stethoscope when blood flows through a narrowed or damaged artery. An abdominal bruit may indicate an abdominal aortic aneurysm (AAA), which is a bulge or swelling in the main blood vessel that runs from the heart down through the chest and tummy.
Shortness of breath is a common symptom of many conditions, but it is not specific to AAA. It can be caused by heart or lung problems, anemia, anxiety, lack of exercise, obesity, and many other factors. Shortness of breath may occur with a ruptured AAA, but it is not a reliable sign of an intact AAA.
Ripping abdominal pain is a severe and sudden pain that may indicate a ruptured AAA, which is a life-threatening situation that requires immediate medical attention. However, an intact AAA usually does not cause any pain or discomfort. Therefore, ripping abdominal pain is not a good indicator of an AAA diagnosis.
Decreased urinary output is a sign of reduced kidney function, which can have many causes such as dehydration, kidney failure, urinary tract obstruction, or medication side effects. Decreased urinary output is not directly related to AAA, although it may occur as a complication of a ruptured AAA or surgery to repair an AAA.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.
In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.
Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.
Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless specifically indicated for the individual patient.
Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.
Correct Answer is D
Explanation
Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.
Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.
Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.
Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment ofthe client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.
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