Page 1723 - Saunders Comprehensive Review For NCLEX-RN

d. Increased pulse
e. Cyanosis
f. Hoarseness, difficulty swallowing
because of pressure from the aneurysm
2. Abdominal aneurysm
a. Prominent, pulsating mass in abdomen,
at or above the umbilicus
b. Systolic bruit over the aorta
c. Tenderness on deep palpation
d. Abdominal or lower back pain
3. Rupturing aneurysm

a. Severe abdominal or back pain
b. Lumbar pain radiating to the flank and
groin
c. Hypotension
d. Increased pulse rate
e. Signs of shock
f. Hematoma at flank area
4. Diagnostic tests
a. Diagnostic tests are done to confirm the
presence, size, and location of the
aneurysm.
b. Tests include abdominal ultrasound,
computed tomography scan, and
arteriography.
5. Interventions
a. Monitor vital signs.
b. Obtain information regarding back or
abdominal pain.
c. Question the client regarding the
sensation of pulsation in the abdomen.
d. Check peripheral circulation, including
pulses, temperature, and color.
e. Observe for signs of rupture.
f. Note any tenderness over the abdomen.
g. Monitor for abdominal distention.
6. Nonsurgical interventions
a. Modify risk factors.
b. Instruct the client regarding the
procedure for monitoring BP.
c. Instruct the client on the importance of
regular PHCP visits to follow the size
of the aneurysm.
d. Instruct the client that if severe back or
abdominal pain or fullness, soreness
over the umbilicus, sudden
development of discoloration in the

1723