While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin in-dividuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
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