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Author Question: While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of ... (Read 32 times)

futuristic

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on: Jun 25, 2018
While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?
 
  a. Teach the patient about aneurysms.
  b. Notify the hospital rapid response team.
  c. Instruct the patient to remain on bed rest.
  d. Document the finding in the patient chart.

Question 2

To determine the effects of therapy for a patient who is being treated for heart failure, which la-boratory result will the nurse plan to review?
 
  a. Troponin
  b. Homocysteine (Hcy)
  c. Low-density lipoprotein (LDL)
  d. B-type natriuretic peptide (BNP)


debra928

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Reply #1 on: Jun 25, 2018
Answer to Question 1

ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin in-dividuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.

Answer to Question 2

ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).


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