A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. What is the nurse's interpretation of this information?
a. The aneurysm clotted and is obstructing blood flow.
b. The aneurysm is expanding and is preparing to rupture.
c. The client feels the inflammation of the aneurysm.
d. This is a normal sensation associated with an AAA.
B
When an aneurysm is expanding or is preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual rupture of the aneurysm.
You might also like to view...
The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication?
a. Draw up the medication using a filtered needle. b. Have injectable naloxone (Narcan) pre-pared and ready at the bedside. c. Prepare to hyperventilate the client before drug administration. d. Discontinue a barbiturate-induced coma before drug administration.
The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities, and higher blood pressure readings in the arms than in the legs. Which assessment will the nurse perform next on this infant?
1. Pedal pulses 2. Pulse oximetry level 3. Hemoglobin and hematocrit values 4. Blood pressure of the four extremities
The nurse has provided teaching about the use of an auto injection of epinephrine. Which statement made by the client indicates further teaching is required?
A. "I will call 911 before I inject the epinephrine." B. "I will use my auto-injector immediately if I think I am having an allergic reaction." C. "I will make sure I have my auto-injector available at all times." D. "I will notify my healthcare provider after I inject the epinephrine."
The client complains of difficulty breathing. Which of the following assessment findings would the nurse commonly associate with that complaint? (Select all that apply.)
1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth 5. Decreased respiratory rate