During the abdominal assessment of an elderly patient, the nurse palpates a mass in the mid-abdomen. What actions should the nurse take? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Percuss the mass.
2. Ask the patient to cough forcefully and reassess.
3. Notify the physician immediately.
4. Auscultate the mass.
5. Ask the patient about any recent pain in the abdomen.
4,5
Rationale 1: If an aneurysm is suspected, percussing the mass could increase the pressure on the weakened site and cause leakage or rupture.
Rationale 2: If this mass is an aneurysm, coughing may increase pressure on the weakened site enough to cause leakage or rupture.
Rationale 3: The nurse should conduct further assessment prior to contacting the physician.
Rationale 4: Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen and a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam.
Rationale 5: Abdominal aneurysms are generally asymptomatic, but the nurse should ask about pain as part of the assessment of this mass.
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