# A 54-year-old male client presents to the emergency department with severe abdominal pain radiating to his back. His vital signs are: blood pressure 90/60 mmHg, heart rate 110 bpm, respirations 24/min, and temperature 98.6°F. The client appears pale and diaphoretic. CT scan reveals a 6.5 cm abdominal aortic aneurysm with possible rupture. While assessing this client, which finding should the nurse report to the healthcare provider (HCP) immediately?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=177033  
> language: ko  
> subject: Adult Health

## 문제

A 54-year-old male client presents to the emergency department with severe abdominal pain radiating to his back. His vital signs are: blood pressure 90/60 mmHg, heart rate 110 bpm, respirations 24/min, and temperature 98.6°F. The client appears pale and diaphoretic. CT scan reveals a 6.5 cm abdominal aortic aneurysm with possible rupture. While assessing this client, which finding should the nurse report to the healthcare provider (HCP) immediately?

## 보기

1. Administer prescribed pain medication immediately to relieve discomfort
2. Maintain the client in a supine position and avoid unnecessary movement **✔ 정답**
3. Encourage deep breathing and coughing to improve oxygenation
4. Apply warm compresses to the abdomen to promote comfort

**정답: 2**

## 해설

Maintaining the client in a supine position and minimizing movement is the priority to prevent further rupture and hemorrhage in a suspected AAA rupture. Other options (pain meds, deep breathing, warm compresses) could increase movement or pressure, worsening the condition.

## 심화 해설

Clinical Priority in Suspected Ruptured AAA

The client’s presentation—severe abdominal pain radiating to the back, hypotension (90/60 mmHg), tachycardia (110 bpm), pallor, and diaphoresis—in the setting of a 6.5 cm abdominal aortic aneurysm on CT strongly suggests a ruptured abdominal aortic aneurysm (rAAA) or contained leak. This is a life-threatening hemorrhagic emergency where the immediate priority is to minimize aortic wall stress and prevent complete free rupture while preparing for emergent surgical intervention.

The correct action is to maintain the client in a supine position and avoid unnecessary movement. Any movement, straining, or positional change can increase intra-abdominal pressure and shear forces on the already compromised aortic wall, potentially converting a contained hematoma into a catastrophic free rupture. Contemporary management principles emphasize deliberate pre-hospital and emergency department strategies that limit hemodynamic fluctuations. This aligns with the modern paradigm shift described in the literature, which includes "deliberate de-escalation of pre-hospital resuscitation" and implementation of clinical pathways designed to stabilize the patient without exacerbating the injury [1]. The goal is to maintain the delicate balance of the tamponade effect provided by the retroperitoneal space, keeping the patient calm and still until definitive vascular surgical control can be achieved.

The other options are contraindicated in this specific clinical scenario:

- Administering prescribed pain medication immediately is a secondary priority and carries significant risk. While pain control is important, the vasodilatory and hypotensive effects of opioid analgesics can further drop the blood pressure and potentially disrupt a tenuous clot at the rupture site. In the context of permissive hypotension for rAAA, aggressive pain management is deferred until the surgical team is ready.

- Encouraging deep breathing and coughing is dangerous. Coughing and the Valsalva maneuver dramatically increase intrathoracic and intra-abdominal pressure, which directly translates to increased transmural pressure across the aneurysm wall, heightening the risk of free rupture.

- Applying warm compresses to the abdomen is contraindicated. External heat causes cutaneous vasodilation, which can shunt blood volume away from the central circulation, worsening the already compromised cardiac output and hypotension. It also does nothing to address the underlying surgical emergency and may delay critical interventions.

The diagnostic challenge in these cases is significant, as even in hemodynamically stable patients with symptomatic AAA, timely recognition of an impending or contained rupture is critical for survival . The nurse’s role at the bedside is to recognize that a patient with a known large AAA and signs of shock is experiencing a vascular catastrophe. The immediate nursing actions are to position the patient supine with the head of the bed flat, minimize all stimulation and movement, secure large-bore intravenous access, type and crossmatch blood, and notify the vascular surgery team and HCP immediately while preparing for emergent transfer to the operating room [1].References (research sources)

- [1]Modern management of ruptured abdominal aortic aneurysm.Research articleScali ST, Stone DH. (2023) · DOI: 10.3389/fcvm.2023.1323465

## 임상 시나리오

Ruptured AAA: Preoperative StabilizationAvoiding Catastrophic Free Rupture in the Emergency Department
The immediate priority for a suspected ruptured AAA is minimizing aortic wall stress. Keep the patient supine and strictly immobile to avoid increasing intra-abdominal pressure.

Implement permissive hypotension. Target a systolic BP of 70-90 mmHg to maintain vital organ perfusion without dislodging the retroperitoneal clot (the tamponade effect). Avoid aggressive fluid resuscitation unless the patient is profoundly shocky.

CautionNever allow straining, coughing, or Valsalva maneuvers. Do not apply pressure or heat to the abdomen. Pain management is necessary but must be titrated carefully to avoid respiratory depression and hypotension.

## 핵심 개념

- **Ruptured Abdominal Aortic Aneurysm (rAAA)** — A life-threatening condition where the weakened aortic wall tears, causing massive internal bleeding; often presents with the classic triad of abdominal/back pain, hypotension, and a pulsatile mass.
- **Tamponade Effect** — A physiological phenomenon in contained aortic ruptures where the retroperitoneal space temporarily seals the leak with a hematoma, preventing immediate exsanguination.
- **Hypotensive Hemostasis** — A resuscitation strategy in rAAA that avoids aggressive fluid resuscitation to prevent raising blood pressure and dislodging the protective clot (pop the clot).

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