To reduce the risk of aneurysm rupture, the nurse should implement all of the following except.
Maintain bedrest with the legs elevated.
Administer antihypertensive and beta-blockers as prescribed.
Instruct client to prevent straining during defecation and avoid holding the breath while moving.
Maintain a calm environment and implement measures to reduce psychologic stress.
The Correct Answer is A
Choice A rationale
Elevating the legs is contraindicated for a client with an aneurysm because it can increase venous return and subsequently increase the pressure within the arterial system. For an abdominal or thoracic aneurysm, the goal is to keep systemic blood pressure low and stable to prevent wall stress. Bedrest is often encouraged, but the legs should remain flat or in a neutral position to avoid any unintended increases in central venous or arterial pressures.
Choice B rationale
Administering antihypertensive medications and beta blockers is a standard evidence based intervention for managing aneurysms. These drugs work by lowering the systemic blood pressure and reducing the heart rate, which decreases the force of blood hitting the weakened vessel wall. By minimizing the dP/dt, or the rate of pressure rise, these medications significantly reduce the risk of dissection or rupture. Maintaining a systolic blood pressure within a narrow, low range is the clinical priority.
Choice C rationale
Preventing straining during defecation is crucial because the Valsalva maneuver significantly increases intra abdominal and intra thoracic pressure. This sudden spike in pressure can place excessive stress on the aneurysmal sac, potentially leading to an immediate rupture. Nurses provide stool softeners and educate clients on proper breathing techniques to ensure that they do not hold their breath or exert themselves physically, thereby maintaining a stable and safe internal pressure environment.
Choice D rationale
Psychological stress triggers the sympathetic nervous system, leading to the release of cortisol and adrenaline. These hormones cause vasoconstriction and increase the heart rate and blood pressure, all of which increase the tension on the arterial wall. By maintaining a calm environment and using stress reduction techniques, the nurse helps keep the client's hemodynamics stable. This holistic approach is essential for preventing the physiological spikes that lead to the catastrophic failure of the aneurysm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.15"]
Explanation
Step 1 is 0.15 mg ÷ 1 mg/ml = 0.15 ml. The nurse will administer 0.15 ml.
Correct Answer is A
Explanation
Choice A rationale
Morphine is the drug of choice after the initial phase of an MI to manage pain that is unresponsive to nitroglycerin. It acts as an opioid analgesic and provides significant peripheral vasodilation, which reduces both preload and afterload, thereby decreasing myocardial oxygen demand. Furthermore, morphine has a calming effect on the central nervous system, effectively reducing the intense anxiety and sympathetic nervous system activation that can further strain an injured heart during the recovery phase.
Choice B rationale
Aspirin is an antiplatelet medication that is administered immediately upon suspicion of a myocardial infarction to prevent the further growth of a coronary thrombus. It is considered part of the initial acute management phase rather than a medication used specifically for the ongoing management of pain and anxiety. While it is essential for long-term secondary prevention, its primary mechanism of action is hematological and does not provide any analgesic or sedative benefits for the patient.
Choice C rationale
Oxygen therapy is indicated in the early stages of a myocardial infarction if the patient's oxygen saturation falls below 90 percent or if they are in respiratory distress. The goal is to increase the oxygen supply to the ischemic myocardial tissue. However, oxygen is a gas used to support oxygenation and is not a pharmacological agent for pain relief or anxiety. Recent guidelines suggest avoiding routine supplemental oxygen in non-hypoxic patients as it may cause vasoconstriction.
Choice D rationale
Nitroglycerin is a potent vasodilator used in the initial acute phase to relieve chest pain by improving coronary artery blood flow and reducing myocardial workload. While it is excellent for managing ischemic pain, it does not address the psychological anxiety or the severe, persistent pain that often follows a major infarction. Once the initial vessel dilation is achieved, morphine is often required to manage the remaining discomfort and the patient's heightened emotional and physiological stress response.
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