NUR 504 Final Exam With 100% Correct
And Verified Answers
Aneurysm - Correct Answer-Forms in the middle layer of a
weakened artery, then pushes on outer layer
AAA is the most common
HTN is the biggest risk factor
CT scan is the best way to diagnose
Interventions → monitor BP, maintain BP
If size is less than 5 cm, monitor it and HTN management, if bigger
than 5 cm or it is producing symptoms then surgery can be done
Do not palpate or press down hard
Do not do an ultrasound because it will rupture it
aneurysmectomy - Correct Answer-resection and repair - high
mortality rate (old - however may still be seen)
open up the patient, clamp the artery, stop the heart and have
machine do the work
High mortality rate because it is a big surgery
Endovascular stent grafts - Correct Answer-•procedure of choice
Complications of repair:
•Conversion to open surgical repair
•Bleeding
•Aneurysm rupture
•Peripheral embolization (blood clot in peripherals)
•Misplacement of stent graft
•Endoleak (opens up and the stent has a leak)
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,Abdominal Aortic Aneurysm (AAA) - Correct Answer-Commonly
asymptomatic and frequently rupture
Pain is gnawing quality, unaffected by movement, lasts
hours/days
Abdominal, flank, back pain
DO NOT PALPATE THE MASS, RISK FOR RUPTURE
Check pulses distal to site, Cap refill, temperature, color
S/S of rupture of aneurysm - Correct Answer-Assess for severe
pain of sudden onset in the back or lower abdomen à may radiate
to groin buttocks or legs.
s/s of rupture: (hypovolemic shock)
•hypotension
•diaphoresis
•decreased LOC
•Oliguria
•Loss of pulses distal to rupture
•Dysrhythmias
lack of oxygenated blood to brain (decreased LOC), kidneys will
not make enough urine (30 cc/hr) → decreased output
Thoracic Aneurysm - Correct Answer-Asymptotic but found by
accident
Back Pain, dyspnea, hoarseness, difficulty swallowing
Rupture → sudden back or chest pain
•Assess for signs of rupture
•Blood pressure control
•Frequent focused perfusion assessment
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,•Specifically blood pressure, pulses, and
peripheral circulation
Check pulses → distal pulses
Aortic Dissection - Correct Answer-
EMERGENCY SITUATION, sudden tear in
tissue
HTN is a big cause
Sharp, ripping, tearing, stabbing pain
N/V, impending doom feeling
Start with HTN, then go into low BP
Call for help, then give fluids/blood
endocarditis - Correct Answer-Most common
cause is infection in the valves
When blood stops → clots and infection risk
(valves)
IVDA → IV drugs can cause the infections
New cardiac murmur from valve impairment
Systemic embolization → very small clots that
clog smaller vessels
Petechiae on the skin !!!!!!!!!
Patients can go home with a PICC, for IV
antibiotics
S/S → Development of Heart Failure, Fever,
chills, night sweats, malaise and fatigue,
anorexia and weight loss, Cardiac murmur,
Systemic embolization-clots break loose and
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, travel randomly through the systemic system
leading to occlusion of smaller vessels
Endocarditis Interventions - Correct Answer-
•Utilization of aseptic techniques
•Focused cardiovascular assessment
•Energy conservation - rest periods
•Anti-embolic stockings
•Monitor for signs of heart failure
Frequent assessment of mental status
•IV antibiotics x4-6 weeks
•Central IV catheter care w/ aseptic
technique
•Monitor for sign & symptoms of reoccurring
or worsening infection
•Dental care (directly affects the heart,
bacteria can go to the heart from mouth)
•Sign & Symptoms of embolic conditions and
heart failure.
myocarditis - Correct Answer-Most common
cause is Viral diseases
Heart muscles cannot work properly, the
ability to pump blood
Fluid is going to back up into body and lungs
S/S → Dyspnea, Orthopnea, Leg swelling,
Palpitations, Syncope
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