Hesi RN Compass Exit B Proctored Exam
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Hesi RN Compass Exit B Proctored Exam
Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.
Select all that apply
Explanation
Rationale: A. Indigestion: Although indigestion may mimic early symptoms of abdominal pathology, the client has not explicitly described heartburn or acid-related symptoms. It is a non-specific complaint and less concerning than the signs suggesting a vascular emergency. B. Tiredness: Fatigue in older adults is often non-specific and may be related to underlying chronic conditions like atrial fibrillation or age-related decline. However, it is not as urgent or directly life-threatening as other findings suggesting vascular compromise. C. Extremity pulse 2+: Pulses rated 2+ are considered normal and symmetric, indicating that peripheral perfusion is currently intact. This finding is stable and does not require immediate follow-up in the context of this clinical picture. D. Pain level in abdomen and back: Severe, gnawing abdominal and back pain raises concern for a potentially rupturing or expanding abdominal aortic aneurysm (AAA). This symptom needs immediate evaluation due to the risk of hemodynamic collapse. E. Pulsatile mass: A pulsatile abdominal mass is a hallmark sign of an AAA. When found on physical exam, especially with accompanying pain, it indicates a life-threatening condition that can lead to sudden rupture and requires emergency imaging and surgical consultation. F. Liquid diarrhea: Although a change in bowel pattern may be relevant, the client reports that this is not unusual for him. Diarrhea is not immediately threatening in this context and is unlikely to be the primary cause of the abdominal symptoms. G. Abdominal bruit: A bruit over a pulsatile abdominal mass indicates turbulent blood flow, further supporting suspicion of aortic aneurysm. This is a critical sign that suggests vascular pathology and requires urgent diagnostic confirmation and intervention.