# Which of the following findings is the most critical for the nurse to report to the healthcare provider when monitoring a 55-year-old female client admitted with dizziness and a history of diabetes? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540310 > language: ko > subject: Adult Health ## 문제 Which of the following findings is the most critical for the nurse to report to the healthcare provider when monitoring a 55-year-old female client admitted with dizziness and a history of diabetes? ## 보기 1. Blood pressure reading of 160/90 mmHg with no prior history of hypertension 2. Complaint of mild back pain that began after lifting a heavy object 3. Absence of bowel sounds in one quadrant with abdominal distension 4. Sudden onset of severe, tearing abdominal pain radiating to the back **✔ 정답** **정답: 4** ## 해설 Sudden severe tearing abdominal pain radiating to the back indicates aortic aneurysm rupture, a life-threatening emergency requiring immediate intervention. Other findings (elevated BP, mild back pain, absent bowel sounds) are less critical in this context. ## 심화 해설 Clinical Reasoning & Priority Setting When a client presents with dizziness and a history of diabetes, the nurse must rapidly differentiate between common comorbid complaints and life-threatening emergencies. The finding that requires immediate reporting is sudden onset of severe, tearing abdominal pain radiating to the back. This symptom is a classic, high-risk red flag for an acute aortic syndrome, specifically an aortic dissection. Pathophysiology and Clinical Significance An aortic dissection occurs when a tear in the tunica intima allows blood to surge into the medial layer, creating a false lumen. This process can propagate along the aorta, compromising branch vessels and leading to end-organ malperfusion or fatal rupture. The "tearing" quality of the pain, described as ripping or shearing, directly correlates with the separation of the aortic wall layers. Radiation to the back is particularly ominous, as it often signals involvement of the descending thoracic aorta, which lies in close anatomical proximity to the posterior thoracic and abdominal cavities [1]. While the classic presentation involves chest pain, the dissection can extend inferiorly, making severe abdominal pain a critical and sometimes atypical presenting symptom. The research by Gelan et al. reinforces that this catastrophic vascular emergency can manifest with atypical signs, and a high index of suspicion is necessary when a patient reports this specific pain characteristic, even without chest involvement [1]. Analysis of Other Options Why are the other findings less critical for immediate reporting? - Option 1: A blood pressure of 160/90 mmHg in a 55-year-old client with diabetes is a significant finding that requires follow-up and management, as it accelerates vascular damage. However, it represents a chronic risk factor rather than an immediate, life-threatening crisis. In the context of a potential aortic dissection, this hypertension could be a contributing etiology, but the pain symptom itself is the direct signal of the active, evolving vascular injury. - Option 2: Mild back pain after lifting is a common musculoskeletal complaint. While it requires assessment, it lacks the hallmark descriptors of vascular catastrophe: "sudden onset," "severe," and "tearing" quality. It is a low-priority symptom in this acute context. - Option 3: Absent bowel sounds in one quadrant with distension could indicate a paralytic ileus or an early bowel obstruction. While this requires nursing and medical intervention, it does not carry the same imminent mortality risk as a rupturing or dissecting aorta. The time frame for intervention for a bowel obstruction is typically measured in hours, whereas an aortic dissection can be fatal in minutes. Nursing Priority and Clinical Judgment The NCLEX-RN prioritizes assessment findings using frameworks like the ABCs (Airway, Breathing, Circulation) and the concept of "what is the most life-threatening?" Aortic dissection directly threatens circulation through massive hemorrhage, cardiac tamponade, or acute aortic regurgitation. The nurse's immediate action upon identifying this critical finding is to report it to the healthcare provider without delay, while simultaneously initiating frequent vital sign monitoring, establishing large-bore intravenous access, and preparing the client for urgent diagnostic studies such as a CT angiogram. The case study by Gelan et al. underscores the high mortality associated with delayed diagnosis, emphasizing that prompt recognition of this pain presentation—even when it deviates from the classic chest pain pattern—is the single most critical nursing action to prevent a fatal outcome [1].References (research sources) - [1]Under the Radar: Back Pain and Acute Kidney Injury as Harbingers of Type A Aortic Dissection.Research articleGelan YD, Ntow M, Sule-Saa S, Adedayo A. (2025) · DOI: 10.7759/cureus.90584 ## 임상 시나리오 Aortic Dissection: The Critical Red FlagRecognizing and Reporting a Vascular Emergency A report of sudden, severe, tearing abdominal pain radiating to the back is a classic sign of an acute aortic syndrome, most critically an aortic dissection. This is a life-threatening emergency where a tear in the aortic intima allows blood to create a false lumen within the vessel wall. The tearing or ripping quality of the pain directly correlates with the separation of the aortic wall layers. Radiation to the back is particularly ominous, often signaling involvement of the descending thoracic aorta. While chest pain is common, the dissection can extend inferiorly, making severe abdominal pain a critical and sometimes atypical presenting symptom. CautionIn a patient with dizziness and diabetes, do not dismiss this pain as a gastrointestinal or metabolic issue. A high index of suspicion is crucial; immediate reporting and intervention are needed to prevent fatal rupture or end-organ malperfusion. Assess bilateral blood pressure and check for a pulse deficit. ## 핵심 개념 - **Aortic Dissection** — A life-threatening condition where a tear in the inner layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. - **False Lumen** — The abnormal channel created within the aortic wall when blood surges through an intimal tear during a dissection. - **Tearing Pain** — A classic descriptor for the pain of aortic dissection, reflecting the sensation of tissue layers being ripped apart. ## 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=540303) - [A nurse is assessing a 72-year-old female client who presents to the emergency department …](https://mymerci.kr/pages/nclex_q.php?qn_id=540304) - [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=540305) - [A 54-year-old male client presents to the emergency department with severe abdominal pain …](https://mymerci.kr/pages/nclex_q.php?qn_id=540306) - [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=540307) - [The nurse is evaluating a client and determines that which of these findings requires the …](https://mymerci.kr/pages/nclex_q.php?qn_id=540308) - [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=540309) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._