High-Acuity Nursing, 7th Edition Class Notes

Improve your learning with High-Acuity Nursing, 7th Edition Class Notes, packed with key course insights.

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DECISION-MAKING CASE SUMMARIES
CASE
NAME

OVERVIEW
MAJOR CASE
DECISIONS

Nils
Rasmussen

Mr. Nils Rasmussen is a 72-
year-old man with a long history
of peripheral atherosclerotic
vascular disease. He has a five-
year history of abdominal aortic
aneurysm (AAA) that has been
treated medically with periodic
monitoring and drug therapy.
Several days ago, after
undergoing his periodic physical
examination and abdominal CT
scan, Mr. Rasmussen’s
cardiovascular healthcare
provider informed him that the
aneurysm had significantly
increased in size when
compared to the previous scan.
Interventional repair of the
aneurysm was recommended.

1.
Identifying and responding to
abnormal test results, vital
signs, or symptoms

2.
Asking appropriate patient
history questions to identify risk
factors

3.
Prioritizing medication
administration

4.
Monitoring for side effects of
treatments

5.
Responding to patient
questions

6.
Recognizing a need for
additional patient teaching

Estimated Case Length:

Difficulty Level: High

Learning Objectives:

Apply knowledge of risk factors associated with aortic aneurysms to care of the patient
with aortic aneurysm.

Describe the pathophysiologic basis of aortic aneurysm.
Apply knowledge of the pathophysiologic basis of aortic aneurysm to care of the
patient with aortic aneurysm.

Assess the patient for clinical manifestations of aortic aneurysm, aneurysm rupture,
and aneurysm dissection.

Identify potential complications of drug therapy in a patient with aortic aneurysm.
Describe the interventional management choices for aortic aneurysm repair.
Demonstrate understanding of management priorities of with aortic aneurysm.
Apply knowledge of patient/family teaching pertaining to the patient who has
undergone aortic aneurysm repair.

Questions
Correct Answers
1. You have just received
Mr. Rasmussen into Room E
and have connected him to
the hemodynamic monitor

Inform the intensivist that the patient’s blood pressure is
significantly elevated.

HIGH ACUITY NURSING #1: AORTIC ANEURYSM
and a pulse oximeter. You
are performing your initial
assessment, which includes:

Oral temp: 97.2 F

BPM: 90/min

Respiratory rate: 14/min

BP of 194/92 (MAP 126
mmHg) O2 saturation of
88%

Pain: abdominal
discomfort rated at 2 out of
10

What is the appropriate
response to these findings?

2. You are obtaining a
nursing history on Mr.
Rasmussen. Which of the
following interview
questions should you ask
him to specifically target
risk factors for
development of aortic
aneurysm? (Select all
that apply)

Do you have a history of high blood pressure?

Do you use tobacco products such as cigarettes or cigars?

Has anyone in your family ever been diagnosed with aortic
aneurysm?

3. Mr. Rasmussen’s
medication orders include:

atorvastatin (Lipitor)
esmolol (Brevibloc)
fentanyl
albuterol (Proventil)
Fluticasone/salmeterol
(Advair)

Which of his medication
order should you initiate
first?

Esmolol

4. You would alert the
health care provider
immediately if Mr.
Rasmussen develops
which of the following
clinical findings? (Select
all that apply.)

Rapid onset of severe flank or back pain

Complaints of numbness in legs

Sudden drop in arterial blood pressure.

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Document Details

Subject
Nursing

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