NURS 160 : Concepts Of Nursing Practice Test! Quiz

A pulsating abdominal mass usually indicates an abdominal aortic aneurysm. This is because an abdominal aortic aneurysm is a condition where the wall of the aorta, the main blood vessel supplying the abdomen and lower body, weakens and bulges. The pulsation is caused by the blood flowing through the enlarged portion of the aorta. It is important to identify and treat an abdominal aortic aneurysm promptly as it can be life-threatening if it ruptures.

Abdominal pain is the most common symptom in a client with an abdominal aortic aneurysm. This is because as the aneurysm grows, it puts pressure on the surrounding tissues and organs, causing pain in the abdomen. This pain may be constant or intermittent and can be described as a pulsating or throbbing sensation. It is important to note that not all individuals with an abdominal aortic aneurysm will experience symptoms, but when they do, abdominal pain is often the primary complaint.

The greatest concern when caring for a preoperative abdominal aortic aneurysm client is aneurysm rupture. Aneurysm rupture can lead to severe internal bleeding, which can be life-threatening. It is important to closely monitor the client for any signs of rupture, such as sudden and severe abdominal or back pain, dizziness, or fainting. Immediate medical intervention is necessary if aneurysm rupture is suspected to prevent further complications and ensure the client's safety.

Atherosclerosis is the most common cause of an abdominal aortic aneurysm. Atherosclerosis is a condition where fatty deposits build up in the arteries, causing them to become narrow and stiff. Over time, this can weaken the walls of the abdominal aorta, leading to the formation of an aneurysm. Diabetes mellitus, hypertension, and syphilis can also contribute to the development of an abdominal aortic aneurysm, but atherosclerosis is the primary cause.

Stimulation of the sympathetic nervous system leads to an increase in heart rate, which is known as tachycardia. This is because the sympathetic nervous system is responsible for the "fight or flight" response, which prepares the body for action. Increased heart rate allows for more blood to be pumped to the muscles, supplying them with oxygen and nutrients needed for physical activity. Therefore, tachycardia is the expected response when the sympathetic nervous system is stimulated.

A bruit is a turbulent blood flow sound that can be heard on auscultation. In the case of an abdominal aortic aneurysm, the weakened artery can cause turbulent blood flow, leading to the presence of a bruit. This sound is distinct and can be heard over the abdominal region of the client. Crackles are abnormal lung sounds and are not associated with an abdominal aortic aneurysm. Duliness refers to a dull sound heard on percussion and is not related to auscultation. Friction rubs are also not associated with an abdominal aortic aneurysm.

The group of symptoms that indicates a ruptured abdominal aortic aneurysm is severe lower back pain, decreased blood pressure, decreased red blood cell count, and increased white blood cell count. This combination of symptoms suggests that there is internal bleeding, as indicated by the decreased blood pressure and decreased red blood cell count. The increased white blood cell count indicates an inflammatory response, which is often seen in cases of infection or injury. The severe lower back pain is a common symptom of a ruptured abdominal aortic aneurysm.

Right sided heart failure is most closely associated with weight gain, nausea, and a decrease in urine output. In right sided heart failure, the right side of the heart is unable to pump blood effectively, leading to a buildup of fluid in the body. This fluid retention can cause weight gain and a decrease in urine output. Additionally, the impaired blood flow can lead to congestion in the liver, causing symptoms such as nausea. Therefore, right sided heart failure is the most likely condition to cause these symptoms.

An abdominal aortic aneurysm is most commonly located distal to the renal arteries. This means that the aneurysm occurs below the level of the renal arteries, which are the blood vessels that supply the kidneys. This location is significant because it allows for the effective management and treatment of the aneurysm, as it is distal to major branching vessels and can be accessed surgically if necessary.

When assessing a client for an abdominal aortic aneurysm, the most commonly palpated area of the abdomen is the middle lower abdomen to the left of the midline. This is because the abdominal aorta, where an aneurysm may occur, is located in this area. Palpating this region allows the healthcare provider to feel for any abnormal pulsations or masses that may indicate an aneurysm. The other options, such as the right upper quadrant or directly over the umbilicus, are not typically associated with the location of an abdominal aortic aneurysm.

Lower back pain is a symptom that usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm. This is because as the aneurysm grows, it can put pressure on the surrounding structures, including the lower back. The pain may be severe and constant, and can radiate to the abdomen or groin. It is important to recognize this symptom as it indicates the need for immediate medical attention, as an untreated ruptured abdominal aortic aneurysm can be life-threatening.

An arteriogram is the definitive test used to diagnose an abdominal aortic aneurysm. This test involves injecting a contrast dye into the arteries and taking X-ray images to visualize the blood vessels. It provides a detailed view of the abdominal aorta and can accurately detect the presence and size of an aneurysm. Other imaging techniques like abdominal X-ray, computed tomography scan, and ultrasound may also be used, but an arteriogram is considered the most definitive test for diagnosing an abdominal aortic aneurysm.

The correct answer is media because the media layer is the middle layer of blood vessels, composed of smooth muscle and elastic tissue. In a client with an aneurysm, which is a weakening and bulging of a blood vessel wall, the media layer is most likely to be damaged due to the increased pressure and stress on the vessel wall. Damage to the media layer can lead to further complications such as rupture or leakage of the blood vessel.