Difficulty: Medium
Average Score: 77%
Simulated
The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply.
Correct answer
A;B;C;E
Rationale
A rupture may cause: A) Oliguria from decreased renal perfusion; B) Dyspnea from hemorrhage pressure; C) Hypotension from blood loss; E) Severe chest pain radiating to the back. Abdominal distention is associated with abdominal, not thoracic, aneurysms.