ANEURYSM FROM NCLEX Flashcards
Mr. Lopez is in the ICU after a repair of an abdominal aortic aneurysm and is experiencing continued slow bleeding from the graft. Due to his unstable condition, visitor restrictions are in place, limiting visits to family members. Mr. Lopez insists on a visit from a medicine man whom his family regularly consults. How should the nurse interpret this request?
A. Faith healers do not qualify for clergy exemption under visitation rules.
B. Medicine men are not recognized by the hospital as legitimate health care providers.
C. Providing holistic care necessitates honoring the client’s belief system.
D. The principle of justice means no client should receive privileges that others do not.
C
After surgery, Ms. Thompson has her abdominal aortic aneurysm resected and replaced with a graft. When she arrives in the recovery room, she is still in shock. What should be the nurse’s priority action?
A. Closely assessing her vital signs, especially respiratory rate.
B. Covering her with several warm blankets.
C. Monitoring her urine output hourly.
D. Positioning her in a Trendelenburg position.
A
Mr. Carter arrives at the emergency department with severe abdominal pain. Diagnostic tests reveal a rapidly enlarging abdominal aortic aneurysm. What action should the nurse anticipate?
A. Discharge home with instructions to follow up with his cardiologist in 24 hours.
B. Admission to the medical unit for observation and medication
C. Admission to the day surgery unit for sclerotherapy.
D. Admission to the surgical unit with resection scheduled.
D
Nurse Parker is training a group of new nurses on the proper techniques for auscultating patients with suspected abdominal aortic aneurysms. She explains which specific sound they should listen for over the abdominal region. What sound should they expect to hear?
A. A bruit.
B. Audible crackles.
C. Friction rubs.
D. A sound of dullness.
A
During a clinical workshop on vascular assessments, Nurse Roberts demonstrates the correct procedure for assessing a patient for an abdominal aortic aneurysm. She explains the specific area of the abdomen that is most commonly palpated for this purpose. Which area should she focus on?
A. The right upper quadrant.
B. The middle lower abdomen to the left of the midline.
C. Directly above the umbilicus.
D. The midline lower abdomen to the right of the midline.
C
Nurse Carter is updating the medical team on a case involving a patient suspected of having an abdominal aortic aneurysm. She highlights the importance of focusing imaging studies on the most common location for this type of aneurysm. Where should the team primarily look?
A. Below the renal arteries.
B. Near the aortic branch.
C. Below the iliac arteries.
D. Above the renal arteries.
A
Nurse Mitchell is evaluating Mr. Green, who is suspected of having an abdominal aortic aneurysm. She reviews the most common symptoms associated with this condition to better focus her assessment. Which symptom is most commonly reported by patients with this condition?
A. Persistent abdominal pain.
B. Excessive sweating.
C. Pain in the upper back.
D. Frequent headaches.
A
Nurse Anderson is closely monitoring Mr. Lee, a 67-year-old patient with a known abdominal aortic aneurysm. Given the risk associated with this condition, she is vigilant for any signs that could indicate rapid expansion and the possibility of an impending rupture. Which symptom should she be most alert to?
A. Gradual onset of dizziness and fatigue.
B. Persistent mild headache.
C. Sudden onset of severe back or abdominal pain.
D. Mild swelling in the lower extremities.
C
Nurse Kim is providing emergency care for Mr. Johnson, a 70-year-old patient suspected of having a ruptured abdominal aneurysm. She carefully monitors his symptoms to confirm the diagnosis. Which group of symptoms should Nurse Kim be most concerned about?
A. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC.
B. Severe lower back pain, decreased BP, decreased RBC, decreased WBC.
C. Severe lower back pain, decreased BP, decreased RBC, increased WBC.
D. Lower back pain, increased BP, decreased RBC, increased WBC.
C
Nurse Adams is conducting a post-operative assessment on Mr. Davis, who recently underwent an abdominal aortic repair. She notices a hematoma in the perineal area and considers the possible complications. Which complication does this finding most likely indicate?
A. Retroperitoneal rupture at the repair site.
B. Stage 1 pressure ulcer.
C. Quick expansion of the aneurysm.
D. Development of a hernia.
A
Nurse Williams is assessing Mr. Barker, who presents with a palpable, pulsating mass in his abdomen. She is determining which condition this symptom most likely indicates. What should she consider as the primary possibility?
A. Gastric distention.
B. An enlarged spleen.
C. An abdominal aortic aneurysm.
D. Gastritis.
C
A 55-year-old man enters the ER with complaints of back pain and feeling fatigued. Upon examination, his blood pressure is 190/100, pulse is 118, and both hematocrit and hemoglobin levels are low. The nurse palpates his abdomen, which is soft and non-tender, and auscultates an abdominal pulse. What is the most likely diagnosis?
A. Congestive heart failure.
B. Presence of an aneurysm.
C. Secondary hypertension.
D. Buerger’s disease.
B
Nurse Patel is evaluating Mr. Thompson, an 80-year-old patient exhibiting signs of increased central venous pressure. She is assessing for physical signs that might indicate the underlying cause. Which disorder should Nurse Patel consider primarily if she observes prominent jugular vein distention?
A. Occurrence of heart failure.
B. Onset of a pneumothorax.
C. Development of a myocardial infarction.
D. Presence of an abdominal aortic aneurysm.
A
Nurse Lee is conducting a community health seminar focusing on vascular health issues. She discusses the risk factors and causes of abdominal aortic aneurysms. Which cause does she identify as the most common for this condition?
A. Presence of diabetes mellitus
B. Development of atherosclerosis
C. High blood pressure
D. Infection with syphilis
B
Nurse James is presenting a lecture on the risk factors associated with abdominal aortic aneurysms. He highlights a condition that is linked to more than 50% of clients diagnosed with this type of aneurysm. Which condition should he emphasize?
A. Peripheral vascular disease
B. Hypertension
C. Diabetes mellitus
D. Syphilis
B
Nurse Thompson is reviewing potential complications with the surgical team for a patient scheduled for abdominal aneurysm surgery. She emphasizes the primary concern they need to monitor for in the preoperative phase. Which complication warrants the greatest vigilance?
A. Elevated blood pressure.
B. Reduced pedal pulses.
C. Occurrence of cardiac arrhythmias.
D. Rupture of the aneurysm.
D
Nurse Cooper is conducting an educational session on vascular health and the anatomy involved in aneurysms. She explains to the nursing students which layers of a blood vessel are most commonly affected in patients with an aneurysm. Which layers should she highlight?
A. Media and adventitia.
B. Intima, media, and adventitia.
C. Intima and media.
D. Intima and adventitia.
C
Nurse Johnson is assessing Mr. Miller, who has been admitted with a suspected abdominal aortic aneurysm (AAA). She reviews his symptoms to confirm the diagnosis. What is a common complaint among clients with an abdominal aortic aneurysm?
A. Back pain that eases when standing.
B. Pulsations felt in the periumbilical area.
C. Reduced urinary output.
D. Numbness in the lower extremities.
B
Nurse Garcia is coordinating diagnostic procedures for a patient with suspected vascular issues. She consults with the medical team to determine the definitive test for diagnosing an abdominal aortic aneurysm. Which test should they primarily consider?
A. Electrocardiogram (ECG)
B. Chest X-ray
C. Complete blood count (CBC)
D. Abdominal ultrasound
D
Aneurysms that burst in the brain are a type of ___.
A. Stroke
B. Heart attack
C. Brain attack
D. Stress relief
A
The most common place for an aneurysm to develop is the ___.
A. Aorta
B. Pulmonary vein
C. Right ventricle
D. Brain
A
Which of the following is NOT a suspected cause of aneurysms?
A. Smoking
B. High blood pressure
C. Drug use
D. Elevated calcium levels
D
When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor?
a. Male gender
b. Turner syndrome
c. Abdominal trauma history
d. Uncontrolled hypertension
D
A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about
a. low back pain.
b. trouble swallowing.
c. abdominal tenderness.
d. changes in bowel habits
B
Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n)
a. hemoglobin count.
b. additional antibiotic.
c. decrease in IV infusion rate.
d. blood urea nitrogen (BUN) level.
D
Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm?
a. Record hourly chest tube drainage.
b. Monitor fluid intake and urine output.
c. Check the abdominal incision for any redness.
d. Teach the reason for a prolonged recovery period.
B
An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first?
a. Obtain the blood pressure.
b. Obtain blood for laboratory testing.
c. Assess for the presence of an abdominal bruit.
d. Determine any family history of kidney disease.
A
After receiving report, which patient admitted to the emergency department should the nurse assess first?
a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse
b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools
c. 50-year-old who is complaining of sudden “sharp” and “worst ever” upper back pain
d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride
C
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?
a. Notify the surgeon and anesthesiologist.
b. Wrap both the legs in a warming blanket.
c. Document the findings and recheck in 15 minutes.
d. Compare findings to the preoperative assessment of the pulses.
A
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?
a. Presence of flatus
b. Loose, bloody stools
c. Hypoactive bowel sounds
d. Abdominal pain with palpation
B
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
a. Monitor the quality and presence of the pedal pulses.
b. Teach the patient the signs of possible wound infection.
c. Check the lower extremities for strength and movement.
d. Help the patient to use a pillow to splint while coughing.
D
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?
a. Weak pedal pulses
b. Absent bowel sounds
c. Blood pressure 137/88 mm Hg
d. 25 mL urine output over last hour
C
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured?
a. Sudden shortness of breath and hemoptysis
b. Sudden, severe low back pain and bruising along his flank
c. Gradually increasing substernal chest pain and diaphoresis
d. Sudden, patchy blue mottling on feet and toes and rest pain
B
Priority nursing measures after an abdominal aortic aneurysm repair include
a. assessment of cranial nerves and mental status.
b. administration of IV heparin and monitoring of aPTT.
c. administration of IV fluids and monitoring of kidney function.
d. elevation of the legs and application of elastic compression stockings.
C
The first priority of collaborative care of a patient with a suspected acute aortic dissection is to
a. reduce anxiety.
b. control blood pressure.
c. monitor for chest pain.
d. increase myocardial contractility.
B
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best?
a. “This type of monitoring system is complex and it is managed by skilled staff.”
b. “The monitoring system helps show whether blood flow to the brain is adequate.”
c. “The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.”
d. “This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.”
B
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 154/68, pulse 56, respirations 12
b. Blood pressure 134/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
A
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
C
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?
a. Blood pressure
b. Oxygen saturation
c. Intracranial pressure
d. Hemoglobin and hematocrit
C
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
C
An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment being given. What action is best for the nurse to take?
a. Ask the family to stay in the waiting room until the initial assessment is completed.
b. Allow the family to stay with the patient and briefly explain all procedures to them.
c. Refer the family members to the hospital counseling service to deal with their anxiety.
d. Call the family’s pastor or spiritual advisor to take them to the chapel while care is given.
B
A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
B
After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patient’s neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.
B
A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
a. Document the BP and ICP in the patient’s record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patient’s bed to 60 degrees.
d. Continue to monitor the patient’s vital signs and ICP.
B
A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?
a. Administer IV 5% hypertonic saline.
b. Draw blood for arterial blood gases (ABGs).
c. Send patient for computed tomography (CT).
d. Administer acetaminophen (Tylenol) 650 mg orally.
A
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c. A 40-year-old patient who lost consciousness for a few seconds after a fall
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
D
After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider?
a. Pulse 102 beats/min
b. Temperature 101.6° F
c. Intracranial pressure 15 mm Hg
d. Mean arterial pressure 90 mm Hg
B
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
a. The staff nurse assesses neurologic status every hour.
b. The staff nurse elevates the head of the bed to 30 degrees.
c. The staff nurse suctions the patient routinely every 2 hours.
d. The staff nurse administers an analgesic before turning the patient.
C
A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?
a. Document intracranial pressure every hour.
b. Turn and reposition the patient every 2 hours.
c. Check capillary blood glucose level every 6 hours.
d. Monitor cerebrospinal fluid color and volume hourly.
C
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse?
a. The apical pulse is slightly irregular.
b. The patient complains of a headache.
c. The patient is more difficult to arouse.
d. The blood pressure (BP) increases to 140/62 mm Hg.
C
Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?
a. Intracranial pressure is 16 mm Hg when patient is turned.
b. Pale yellow urine output is 1200 mL over the last 2 hours.
c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours.
B
When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?
a. The patient takes warfarin (Coumadin) daily.
b. The patient’s blood pressure is 162/94 mm Hg.
c. The patient is unable to remember the accident.
d. The patient complains of a severe dull headache.
A
Following surgery for an abdominal aortic aneurysm, a patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Document the CVP and continue to monitor.
d. Elevate the head of the patient’s bed to 45 degrees.
B
