Question

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

1. The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic.
2. The client reports feeling nauseated.
3. The client has been taking an antihypertensive for the past 3 years but forgot to take it today.
4. The client reports increasing severe back pain.

Answer 1

The most indicative sign of a potential aortic aneurysm rupture among the presented options is 4.increasing severe back pain, but the nurse must assess all patient symptoms and history for a thorough and accurate evaluation.

Step-by-step explanation:

A client arriving in the emergency department reporting intense pain in the abdomen that feels like a heartbeat could be a sign of an abdominal aortic aneurysm.

Assessing the risk of a potential rupture requires careful consideration of the client's symptoms and vital signs.

The most indicative sign of a potential rupture of an aortic aneurysm from the options provided would be: 4. increasing severe back pain.

This symptom can be associated with the tearing of the layers of the aorta and potential imminent rupture, which is a life-threatening emergency.

However, it is important for the nurse to assess all aspects of the patient's presentation, as abdominal aortic aneurysm can have common symptoms with other emergency conditions such as acute myocardial infarction (MI), which might present with angina pectoris, dyspnea, and diaphoresis.

Therefore, a nurse should also consider the presence of symptoms like skin paleness and diaphoresis, nausea, and the history of blood pressure management in their overall assessment.