Difficulty: Medium
Average Score: 80%
Simulated
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
Correct answer
A,B,D
Rationale
If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.