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Rationale:

• Auscultation of bruit: A bruit heard over the abdomen suggests turbulent blood flow, a key feature of aortic aneurysm. It results from abnormal dilation of the aortic vessel, which disrupts normal flow and produces an audible vibration on auscultation.
• Pulsatile mass: A pulsatile mass in the periumbilical area is highly suggestive of an abdominal aortic aneurysm. This occurs due to the expansion of the weakened aortic wall, making the pulse visible or palpable through the abdominal wall.
• Fatigue: Fatigue can appear in both conditions. In gastric cancer, it may be due to anemia or cancer-related systemic effects. In aortic aneurysm, it may be linked to poor circulation or cardiac workload from concurrent conditions like atrial fibrillation.
• Indigestion: Indigestion is more common in gastric cancer due to delayed gastric emptying, mucosal irritation, or tumor growth. It presents as bloating, discomfort, or heartburn and is not typically associated with aortic aneurysm.
• Feeling of fullness: Early satiety or a persistent sense of fullness can occur with gastric cancer as tumors restrict gastric expansion or interfere with digestion. This symptom is uncommon in aortic aneurysm unless the aneurysm is compressing nearby digestive organs, which is rare.
• Back pain: Back pain is a key warning sign of aortic aneurysm, especially if the aneurysm is enlarging or nearing rupture. It results from pressure on surrounding tissues or vertebrae and requires urgent follow-up to prevent life-threatening complications.

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.

Rationale:

• Place client on 2 L/minute oxygen: The client's oxygen saturation is borderline at 94%, and with suspected aortic aneurysm and possible compromise, low-flow oxygen can help ensure adequate tissue oxygenation. This intervention is safe and aligns with the standing PRN order.
• Start 0.9% sodium chloride fluid bolus: Given the client’s low-normal blood pressure and risk for aneurysm rupture, fluid resuscitation may be needed to support perfusion. Carefully titrated fluids are appropriate to maintain hemodynamic stability while awaiting definitive surgical management.
• Ensure surgical consent has been completed: Time is critical in suspected abdominal aortic aneurysm (AAA) rupture. Preoperative preparation, including confirming surgical consent, should be done early in anticipation of emergent vascular intervention.
• Insert indwelling urinary catheter: This is contraindicated until the aneurysm is surgically managed or ruled out. Inserting a catheter increases intra-abdominal pressure and may worsen an unstable aneurysm. Additionally, unnecessary movement may elevate the risk of rupture in a fragile vessel.
• Document any skin lesions on lower legs: Peripheral vascular disease is often comorbid with aneurysms. Noting skin lesions helps establish a vascular baseline and may inform intraoperative risk or postoperative wound healing considerations.
• Mark pedal pulse sites with a single use marker: Pulse marking is essential preoperatively in vascular cases to monitor distal perfusion post-surgery. Marking now ensures pulses can be quickly located after potential surgical repair of the aneurysm.

Rationale for Correct Choices:

• Blood pressure of 120/74 mm Hg: This is within the normal range and indicates stable cardiovascular function, which supports discharge readiness following an aortic aneurysm intervention.
• Pedal pulse of 2+ or better: A 2+ pulse signifies adequate peripheral perfusion. It is important for assessing vascular integrity postoperatively, especially for patients with a history of aneurysmal disease.
• Absence of numbness or tingling in feet: Normal neurovascular sensation in the lower extremities suggests intact peripheral nerve and vascular supply, a critical discharge criterion after vascular complications.
• Client has urine output of 1,600 mL in 24 hours: This volume reflects adequate renal perfusion and fluid balance, within the normal range (800-2000 mL/day for adults) both of which are necessary to confirm the kidneys are functioning properly post-recovery.
• Creatinine of 1.2 mg/dL (106 mmol/L): This value is within normal limits (0.6-1.2 mg/dL), indicating that renal function is preserved and not compromised by the previous cardiovascular event or interventions.

Rationale for Incorrect Choices:

• Capillary refill of 4 seconds in lower extremities: A capillary refill time longer than 2–3 seconds suggests impaired perfusion, which would warrant further evaluation before discharge.
• Pupils equal and nonresponsive to light: This indicates a serious neurological deficit, potentially related to brain injury or altered consciousness, and is incompatible with safe discharge.
• Skin that is pale, cool to touch: This suggests possible peripheral hypoperfusion or systemic circulatory compromise and would need to be resolved before considering discharge.

Calculation:

• Convert the client's weight from pounds (lb) to kilograms (kg).

Weight in kg = 110 lb / 2.2 lb/kg

= 50 kg.

• Calculate the total units of dalteparin the client should receive daily.

Daily units = Desired units/kg × Weight (kg)

= 150 units/kg × 50 kg = 7500 units.

• Determine the volume to administer based on the available prefilled syringe.

The medication is available in a 7,500 units/0.3 mL prefilled syringe.

Since the calculated daily dose (7500 units) exactly matches the units in one prefilled syringe (7500 units), the volume to administer is the volume of that syringe.

Volume to administer:

= 0.3 mL.

Rationale for Correct Choices:

• Sleeping difficulty: The client reports insomnia, a core symptom of post-traumatic stress disorder (PTSD) and depression. Sleep disturbances are common among individuals with trauma exposure and are particularly concerning when paired with suicidal ideation.
• Hypervigilance: The client's constant surveying of the environment and being easily startled are hallmark signs of hypervigilance. This symptom reflects heightened arousal often seen in PTSD, especially in veterans who have experienced combat trauma.

Rationale for Incorrect Choices:

• Withdrawn mood: While the client appears quiet and withdrawn, this behavior is more observational than subjective. The question asks for subjective symptoms, which are the client’s personal experiences rather than behaviors noted by others.
• Alcohol on breath: The presence of alcohol on the breath is an objective clinical finding, not a subjective symptom reported by the client. Although relevant to her condition, it doesn’t fulfill the criteria specified in the prompt.
• Blood pressure of 144/92 mmHg: This is an objective vital sign and not a subjective symptom. Elevated blood pressure may be due to anxiety but is not something the client reports feeling.
• Nightmares: Though she has nightmares, this was part of the background history already acknowledged. Hypervigilance is more acute and directly observable during this clinical encounter.
• Latency of response: While the client requires prodding to give answers, this is an observed behavior and not a reported internal experience, so it does not qualify as a subjective symptom.
• Respirations of 20 breaths/minute: This is an objective clinical measurement. It may suggest anxiety, but it is not subjectively reported by the client.

Rationale:

• Avoidance: Avoidance of reminders of the trauma, including people, places, or conversations related to the event, is a core diagnostic criterion for PTSD. The client avoids visiting fellow platoon members, suggesting avoidance behavior linked to her combat trauma.
• Suicidal ideation: Thoughts of death or suicide are hallmark symptoms of MDD. The client was found writing a suicide note and planning to shoot herself, which strongly supports the diagnosis of MDD.
• Nightmares: Recurrent distressing dreams or nightmares related to the traumatic event are common in PTSD. The client reports frequent nightmares linked to her war experience.
• Feelings of guilt: Excessive guilt is common in MDD, often irrational and self-deprecating. In PTSD, survivors’ guilt is prevalent, especially when others died in the traumatic event, as expressed by the client lamenting that her life was spared over her comrades'.
• Lack of interest: Markedly diminished interest or pleasure in previously enjoyed activities is a core symptom of MDD. The client’s withdrawal from social connections reflects this loss of interest.
• Sleep disturbance: Insomnia is prevalent in GAD due to excessive worry, in MDD due to mood dysregulation, and in PTSD due to nightmares and hyperarousal. The client’s reported insomnia applies to all three conditions.

Rationale for Correct Choices:

• Cortisol, epinephrine, and norepinephrine: These are key stress hormones activated during the fight-or-flight response. In PTSD, their persistent elevation is associated with symptoms like anxiety, agitation, and increased alertness, especially during perceived threats.
• Hypervigilance: Hypervigilance refers to an enhanced state of sensory sensitivity and constant scanning of the environment for threats. It is a hallmark of PTSD, evident in the client's easily startled behavior and environmental scanning.

Rationale for Incorrect Choices:

• Acetylcholine, epinephrine, and norepinephrine: Acetylcholine plays a greater role in attention and memory, not the stress response. Cortisol, not acetylcholine, is a more relevant hormone in PTSD-related hyperarousal and stress regulation.
• Dopamine, norepinephrine, and epinephrine: While dopamine influences motivation and pleasure, cortisol is more directly tied to the physiological stress response seen in PTSD. Omitting cortisol weakens the connection to stress-induced hyperalertness.
• Bradyphrenia: Bradyphrenia refers to slowed thinking, which is not typical in hyperaroused PTSD states. The client shows heightened awareness, not cognitive slowing.
• Hypoactivity: Hypoactivity implies reduced movement or response, which does not align with the client’s constant environmental scanning and heightened alertness. Hyperactivity, not hypoactivity, is more consistent with hypervigilance.

Rationale:

• Assess for pattern of bowel movements: Sertraline, a SSRI, commonly causes gastrointestinal side effects, including diarrhea or constipation. Monitoring the client's bowel movement pattern is essential to detect and manage these potential adverse effects.
• Monitor suicidal ideation: Clients with PTSD and major depressive symptoms, especially those recently expressing suicidal intent, require close monitoring for suicidality when initiating SSRIs like sertraline, as energy to act on suicidal thoughts may increase before mood improves.
• Weigh client weekly: SSRIs, including sertraline, can lead to weight changes. Regular weight monitoring helps detect significant weight gain or loss, especially in clients with changes in appetite or nutrition due to mood disorders.

• Offer frequent sips of fluids: There is no current evidence of dehydration or dry mouth. SSRIs like sertraline do not routinely require fluid intake encouragement unless side effects or clinical symptoms indicate a need.
• Watch for hypotension: Sertraline is not commonly associated with hypotension. Orthostatic hypotension is more typical with tricyclic antidepressants or antipsychotics, not SSRIs.

Rationale for Correct Choices

• 4 to 8 weeks: Sertraline, an SSRI, typically requires 4 to 8 weeks to reach its full therapeutic effect. This time frame allows for sufficient serotonin modulation, necessary for symptom improvement in conditions like PTSD and depression.
• Eye movement desensitization: Eye Movement Desensitization and Reprocessing (EMDR) is specifically recommended for PTSD. It involves guided eye movements that help the brain reprocess traumatic events and reduce emotional disturbance.
• Deep breathing: Deep breathing promotes parasympathetic nervous system activation, helping reduce anxiety and hyperarousal. It is a simple, accessible coping strategy to complement therapy and medication.

Rationale for Incorrect Choices

• 1 to 2 days: This timeframe is too short for an SSRI to have significant therapeutic effects. Any changes in mood or anxiety within this period are typically not due to the medication’s primary mechanism of action.
• 10 to 14 days: Although some mild improvement may begin, full therapeutic benefits of sertraline are not typically seen within this period. Clients are advised to continue consistent use for several weeks.
• Cognitive behavioural therapy: CBT is effective for many mental health disorders, including PTSD, but it does not involve the “reprocessing” component referenced.
• Prolonged exposure therapy: Prolonged exposure is used for PTSD treatment but focuses on gradually confronting trauma-related memories. It lacks the reprocessing element emphasized in the question.
• Progressive muscle relaxation: While useful for anxiety reduction, it is more complex and less immediate than deep breathing. It also requires a quiet space and more time, which may limit spontaneous use.
• Guided imagery: Guided imagery can reduce anxiety but involves visualization, which may not be suitable for individuals with intrusive trauma-related images. Deep breathing is simpler and more universally applicable.