NCLEX-PN® ExaminationPhysiological AdaptationMedium
A client is admitted with a suspected ruptured abdominal aortic aneurysm (AAA). The nurse should monitor for which of the following classic signs of a ruptured AAA?
- ALocalized abdominal tenderness, rebound tenderness, and guarding.
- BSevere, sudden onset back or abdominal pain, hypotension, and pulsatile abdominal mass.
- CGradual onset of flank pain, hematuria, and hypertension.
- DSharp, tearing chest pain radiating to the back, unequal blood pressures in arms, and widened mediastinum on X-ray.
Show answer & explanationAnswer & explanation
Correct answer: B. Severe, sudden onset back or abdominal pain, hypotension, and pulsatile abdominal mass.
The classic triad of symptoms for a ruptured abdominal aortic aneurysm (AAA) includes sudden, severe pain in the back or abdomen, hypotension (due to blood loss), and a pulsatile abdominal mass. This is a medical emergency requiring immediate surgical intervention.
Why the other options are wrong
- A. These symptoms are classic for peritonitis, which could occur with a ruptured viscus but not typically a ruptured AAA as the primary presentation.
- C. These symptoms are more indicative of kidney stones or pyelonephritis, not a ruptured AAA.
- D. These symptoms describe an aortic dissection, which is distinct from a ruptured AAA despite involving the aorta.
Ruptured Abdominal Aortic Aneurysm (AAA)
A life-threatening medical emergency where a weakened section of the aorta in the abdomen bursts, leading to massive internal bleeding.
- Classic triad: sudden, severe abdominal/back pain, hypotension, pulsatile abdominal mass.
- Risk factors include atherosclerosis, hypertension, smoking, male gender, age >65.
- Requires immediate surgical repair.
Memory trick: AAA Burst = Pain, Low BP, Pulsing Belly!