Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
15. A client is admitted with a history of an abdominal aortic aneurysm. A nurse should know that the client has an impending rupture of the aneurysm if the client reports:
. Severe right upper quadrant abdominal pain.
. Persistent or intermittent lower back pain.
. Absent pedal pulses in both extremities.
. Chest pain in the epigastric region.
Test-Taking Tip
Visualize the location of the abdominal aorta.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because abdominal pain from an impending rupture is localized in the middle or lower abdomen to the left of the midline. Answer 2 is correct because the aneurysm is pressing on the lumbar nerves. Severe back or middle or lower abdominal pain are signs of impending rupture. If the aneurysm ruptures, the back pain will be constant. Answer 3 is incorrect because circulation would not be impaired before rupture. Answer 4 is incorrect because the pain is lower abdomen or back. Epigastric pain is more consistent with cardiac or gastric problems.