Patho Patho #81
The nurse is completing the admission assessment on a client with a suspected aortic abdominal aneurysm. Which symptom requires immediate intervention?
- Reports of headache 3/10.
This answer choice is not correct as a report of sudden, sever back pain is a more critical finding in a client with a diagnosed AAA.
- Bruit heard upon auscultation of the abdomen.
This answer choice is not correct as the auscultation of a bruit in a client with a AAA is an expected manifestation. Reports of sudden back pain indicates possible rupture and is the higher priority finding.
- Blood pressure of 102/68.
This answer choice is not correct as a blood pressure of 102/68 is adequate. It is desirable to prevent elevated blood pressure in a client with a confirmed AAA in efforts to prevent rupture.
- Sudden onset of severe back pain.
This answer is correct because reports of sudden, severe back pain in a client with a AAA indicates possible rupture which is a critical complication requiring immediate intervention.
The focus of this question is asking the nurse to determine the most critical manifestation associated with a diagnosis of an abdominal aortic aneurysm (AAA). The most common underlying etiology for AAA is chronic, severe, poorly controlled hypertension. When an AAA ruptures, often the client will report a sudden onset of sharp stabbing back pain and the client should be immediately assessed for additional signs and symptoms of rupture and hemorrhage.
AAA is a localized enlargement of the abdominal aorta which is caused by a weakening of the vessel due to long standing high blood pressure. A AAA is usually asymptomatic unless rupture occurs. Signs that a AAA has ruptured include reports of sudden, sharp pain in the back, leg, or neck. A ruptured AAA leads to hemorrhage and the client will develop hypovolemic shock if the rupture is not surgically repaired immediately.
Test Taking Tip
Pain is treated as a psychological need on NCLEX and nursing exams unless it is severe or indicates a life threatening condition.