Patho Patho #81

Question

The nurse is completing the admission assessment on a client with a suspected aortic abdominal aneurysm. Which symptom requires immediate intervention?

Answers

  1. Reports of headache 3/10.
    • Rationale:

      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.

  2. Bruit heard upon auscultation of the abdomen.
    • Rationale:

      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.

  3. Blood pressure of 102/68.
    • Rationale:

      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.

  4. Sudden onset of severe back pain.
    • Rationale:

      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.

Overview

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.

Explanation

Learning Outcomes

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.

Video Rationale