# A nurse is assessing a 72-year-old female client who presents to the emergency department with complaints of severe back pain. Which assessment finding would be most indicative of a ruptured abdominal aortic aneurysm?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=177030  
> language: ko  
> subject: Adult Health

## 문제

A nurse is assessing a 72-year-old female client who presents to the emergency department with complaints of severe back pain. Which assessment finding would be most indicative of a ruptured abdominal aortic aneurysm?

## 보기

1. Pulsatile abdominal mass with hypotension and tachycardia **✔ 정답**
2. Gradual onset of cramping abdominal pain with normal vital signs
3. Sharp chest pain radiating to the left arm with diaphoresis
4. Intermittent claudication with diminished peripheral pulses

**정답: 1**

## 해설

A pulsatile abdominal mass with hypotension and tachycardia is the classic triad indicating AAA rupture, as it combines structural abnormality with signs of hemorrhagic shock. Other options do not align with AAA rupture presentation.

## 심화 해설

Understanding the Clinical Presentation

When assessing a client with severe back pain, the nurse must rapidly differentiate between life-threatening vascular emergencies and less critical musculoskeletal or cardiac conditions. A ruptured abdominal aortic aneurysm (rAAA) is a surgical emergency with extremely high mortality, often presenting with a classic triad of symptoms. The assessment finding most indicative of this condition is a pulsatile abdominal mass accompanied by hypotension and tachycardia. This combination reflects the underlying pathophysiology: the pulsatile mass is the dilated, leaking aorta, while hypotension and tachycardia are compensatory responses to acute, massive hemorrhagic shock [3,4].

Pathophysiology and Clinical Correlation

In a ruptured AAA, the integrity of the aortic wall is compromised, allowing blood to escape into the retroperitoneal space. This leads to a rapid depletion of circulating volume. The body's immediate compensatory mechanism involves the sympathetic nervous system, which triggers an increase in heart rate (tachycardia) to maintain cardiac output despite falling stroke volume. Simultaneously, systemic vascular resistance increases, but this is insufficient to prevent a drop in blood pressure (hypotension) as the hemorrhage continues. The palpable, pulsating mass is a direct physical manifestation of the dilated aortic segment expanding with each heartbeat. This presentation is distinct from other options because it directly links a structural abdominal finding with systemic signs of shock .

Analysis of Incorrect Options

- Option 2 (Gradual onset of cramping abdominal pain with normal vital signs): This presentation is more consistent with a gastrointestinal or genitourinary condition, such as a bowel obstruction or renal calculus. A ruptured AAA typically involves sudden, severe, and constant pain, not gradual cramping. Furthermore, the presence of normal vital signs argues strongly against a rupture causing significant hemorrhage, as hemodynamic instability is a hallmark of rAAA .

- Option 3 (Sharp chest pain radiating to the left arm with diaphoresis): This is the classic presentation of an acute myocardial infarction. While a myocardial infarction can lead to cardiogenic shock, the pain location and radiation pattern are distinct from the back and abdominal pain of a ruptured AAA. Diaphoresis is a common feature of both conditions due to sympathetic activation, but the primary pain pattern points to a cardiac origin.

- Option 4 (Intermittent claudication with diminished peripheral pulses): This finding is characteristic of peripheral arterial disease. The pain occurs with exertion and is relieved by rest, which is completely different from the constant, severe pain at rest seen in a rupture. While a large AAA can sometimes present with diminished pulses due to thrombus or dissection, the intermittent nature of the pain and the absence of shock signs make this a chronic, not an acute emergency, presentation.

Key Assessment Priorities and Risk Stratification

For the NCLEX-RN, recognizing the "hypotension plus pulsatile mass" equation is critical for prioritizing care. This assessment finding indicates that the client is in a state of profound hemorrhagic shock and requires immediate intervention. Research on risk stratification for rAAA confirms that admission hemodynamic parameters, such as systolic blood pressure and heart rate, are powerful predictors of in-hospital mortality . A client presenting with this triad has already entered a high-risk category. The nurse's immediate actions must focus on establishing large-bore intravenous access for fluid resuscitation, preparing for rapid blood transfusion, and alerting the surgical team for emergent repair, which may involve endovascular techniques [1,2]. Notably, while endovascular repair is a common approach, anatomical factors and the urgency of rupture can complicate the procedure, and outcomes can vary based on patient-specific factors like sex and aneurysm anatomy [1,2]. The initial nursing assessment is the pivotal step that triggers this entire life-saving sequence.

## 임상 시나리오

Ruptured AAA: Rapid RecognitionKey assessment findings for immediate intervention
The classic triad for a ruptured abdominal aortic aneurysm is severe back or abdominal pain, a pulsatile abdominal mass, and hypotension with tachycardia. This reflects acute hemorrhagic shock from retroperitoneal bleeding.

Do not rely on the presence of all three signs; a high index of suspicion is needed. The mass may be obscured by obesity. Hypotension is often a late and ominous finding, indicating a loss of over 30-40% of circulating blood volume.

Critical ActionIf a ruptured AAA is suspected, avoid deep palpation of the mass to prevent dislodging a clot. Immediately establish two large-bore IV lines, type and crossmatch for massive transfusion, and prepare for emergency surgical repair without delay.

## 핵심 개념

- **Ruptured Abdominal Aortic Aneurysm (rAAA)** — A life-threatening surgical emergency where the dilated aortic wall tears, causing massive internal hemorrhage, often into the retroperitoneal space.
- **Pulsatile Abdominal Mass** — A palpable, throbbing mass in the abdomen that expands with each heartbeat, representing the dilated, leaking aorta in an AAA.
- **Hemorrhagic Shock** — A state of inadequate tissue perfusion caused by acute blood loss, characterized by compensatory tachycardia and hypotension.
- **Classic Triad of rAAA** — The hallmark clinical presentation consisting of severe abdominal or back pain, a pulsatile abdominal mass, and hypotension.

## 같은 주제 문제

- [A nurse is assessing a 70-year-old male client with a known 5.2 cm abdominal aortic aneury…](https://mymerci.kr/pages/nclex_q.php?qn_id=177029)
- [A 65-year-old male is rushed to the emergency department with severe, tearing abdominal pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=177031)
- [A 54-year-old male client presents to the emergency department with severe abdominal pain …](https://mymerci.kr/pages/nclex_q.php?qn_id=177033)
- [A nurse is caring for a client with a thoracic aortic aneurysm who is scheduled for surgic…](https://mymerci.kr/pages/nclex_q.php?qn_id=177034)
- [The nurse is evaluating a client and determines that which of these findings requires the …](https://mymerci.kr/pages/nclex_q.php?qn_id=177036)
- [A nurse is caring for a 45-year-old female client with suspected thoracic aortic aneurysm …](https://mymerci.kr/pages/nclex_q.php?qn_id=177037)
- [Which of the following findings is the most critical for the nurse to report to the health…](https://mymerci.kr/pages/nclex_q.php?qn_id=177038)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._