Med Surge 2- Cardiac EAQS

What medications should the nurse expect to include in the teaching plan for the patient to decrease the risk of cardiovascular events and death for peripheral artery disease (PAD) patients? Select all that apply. -Ramipril (Altace) -Cilostazol (Pletal) -Simvastatin (Zocor) -Clopidogrel (Plavix) -Warfarin (Coumadin) -Aspirin (acetylsalicylic acid)

Ramipril, Simvastatin, and Aspirin Angiotensin-converting enzyme inhibitors (e.g., ramipril) are used to control hypertension. Statins (e.g., simvastatin) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol is used for intermittent claudication, but it does not reduce cardiovascular disease (CVD) morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin) are not recommended to prevent CVD events in PAD patients.

A nurse is caring for a patient after an open aneurysm repair. Which interventions should the nurse perform? Select all that apply. -Record the amount and character of nasogastric output. -Assess for bowel sounds every hour -Ensure complete bed rest until the fourth postoperative day. -Provide ice chips or lozenges to the patient as needed. -Note passing of flatus.

Record the amount and character of nasogastric output, Provide ice chips or lozenges to the patient as needed. and Note passing of flatus, The nurse should record the amount and character of nasogastric output. While the patient is not taking food or water by mouth, the nurse should ensure oral care frequently, and ice chips or lozenges can help soothe a dry or irritated throat. The passing of flatus signals returning bowel function and should be noted. Bowel sounds should be assessed for every 4 hours. The nurse should encourage early ambulation, since this can help with the return of the patient's bowel function.

The patient has chronic venous insufficiency (CVI) and a venous ulcer, peripheral artery disease (PAD), and an arterial stasis ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have prescribed for them. What assessment by the nurse would cause the application of compression stockings to harm the patient? -Rest pain -High blood pressure -Elevated blood sugar -Dry, itchy, flaky skin

Rest Pain Rest pain occurs as PAD progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The registered nurse should be the one to obtain the prescription and instruct the UAP to apply compression stockings if they are prescribed.

The nurse is assessing a patient with valvular heart disease. The patient has not experienced any symptom of heart failure. How should the nurse classify this patient according to the American College of Cardiology/American Heart Association (ACC/AHA) stages of heart failure? -Stage A -Stage B -Stage C -Stage D

Stage B According to ACC/AHA the nurse should classify this patient as stage B. Stage B patients have structural heart disease without any sign or symptom. Stage A patients are at high risk for heart failure with hypertension, diabetes, or metabolic syndrome. Stage C patients have prior or current symptoms of heart failure associated with a known underlying structural heart disease. Stage D patients have refractory heart failure; they have severe symptoms at rest despite maximal medical therapy and require specialized interventions.

Pulse Pressure

Systolic-Diastolic

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? -Application of topical antibiotics to venous ulcers -Maintaining the patient's legs in a dependent position -Administration of oral or subcutaneous anticoagulants -Teaching the patient the correct use of compression stockings

Teaching the patient the correct use of compression stockings.

A diabetic patient underwent an ankle-brachial index (ABI) test. The result of the test is 1.10. How should the nurse interpret the test result? -The patient has peripheral arterial disease -The patient has normal ABI -The patient has falsely elevated ABI -The patient has borderline ABI

The patient has a falsely elevated ABI Ankle-brachial index (ABI) test is a screening tool for peripheral arterial disease. An ABI of 1.10 is a normal value in healthy adults. However, in diabetic patients the arteries are calcified and non compressible, which often result in a falsely elevated ABI. An ABI of 1.10 does not indicate PAD. The value can be considered normal in healthy adults, but not in diabetic patients as their blood vessels are

INR (International rationalize number)

The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. The nurse will monitor for signs and symptoms of a ruptured aneurysm, including which of these? Select all that apply. -Back or flank ecchymosis -Sudden, severe low back pain -Sudden shortness of breath and hemoptysis -Patchy blue mottling on feet and toes and rest pain -A pulsatile mass in the periumbilical area, slightly left of the midline

Back or flank Ecchymosis, and sudden, severe, low back pain. Rupture of an aneurysm is the most serious complication. If rupture occurs into the retroperitoneal space, bleeding may be controlled by surrounding anatomic structures, preventing exsanguination and death. In this case the patient often has severe back pain and may or may not have back or flank ecchymosis (Grey Turner's sign). If rupture occurs into the thoracic or abdominal cavity, more than 90% of patients will die from massive hemorrhage. The patient who reaches the hospital will be in hypovolemic shock with tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness. A pulsatile mass in the abdomen is indicative of an aneurysm that has not ruptured. Sudden shortness of breath and patchy blue mottling on toes and feet are not indicative of a ruptured aneurysm. A pulsatile mass is found in an abdominal aortic aneurysm, but it is not a symptom of a ruptured aneurysm.

The nurse is performing a physical assessment on a patient with chronic venous insufficiency. Which manifestation involving the lower extremities should the nurse expect? -Shiny skin -No swelling -Brown color -Absent pulses

Brown Color Brown is the characteristic skin color of the lower leg in chronic venous insufficiency. The brownish skin discoloration occurs when the red blood cells leak from the capillaries, break down, and release hemosiderin. Shiny skin, no edema, and absent pulses are manifestations of peripheral artery disease.

After the first year following a heart transplant, the nurse knows that which is the major cause of death? -Infection -Acute rejection -Immunosuppression -Cardiac vasculopathy

Cardiac Vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease [CAD]) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increase the patient's risk of an infection.

After the first year following a heart transplant, the nurse knows that which is the major cause of death? Infection Acute rejection Immunosuppression Cardiac vasculopathy

Cardiac Vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease [CAD]) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increase the patient's risk of an infection.

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should assess diligently the patient for which complication early in the postoperative period until the medication is resumed? -Decreased cardiac output -Increased blood pressure -Cerebral or pulmonary emboli -Excessive bleeding from incision or intravenous (IV) sites

Cerebral or Pulmonary Emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could form again. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

The nurse understands that venous ulcers are characterized by which assessment findings? Select all that apply. -Bluish tinge of the extremities -Cap refill greater than three seconds -Delayed wound healing -Well-defined edges along the wound -Wounds proximal to the medial malleolus

Delayed wound healing and wounds proximal to the medial malleoulus. Lesions with delayed healing and located near or at the medial malleolus are classic findings associated with poor venous return and venous ulcers. A blue tinge to the skin is associated with decreased arterial oxygenation to the tissue. Venous ulcers have a bronze-brown pigmentation and cap refill is less than three seconds with venous disease. Well-defined edges are seen with arterial ulcers.

The nurse is teaching a patient who has been newly diagnosed with Raynaud's phenomenon to avoid potential triggers, which include which of these? Select all that apply. -Wearing gloves -Drinking coffee -Exposure to heat -Emotional upsets -Cigarette smoking

Drinking coffee, Smoking cigarettes, emotional upsets Exposure to cold (not heat), emotional upsets, tobacco use, and caffeine often bring on symptoms of Raynaud's phenomenon. Wearing gloves often is recommended to protect the hands from exposure to cold.

A nurse is caring for an older adult patient who has been admitted to the emergency department with pain, dyspnea, and lower extremity edema. The patient is diagnosed with diastolic heart failure. Which clinical finding aids in the diagnosis of diastolic heart failure? -Low filling pressures -Ejection fraction less than 45% -Ejection fraction of 55% -Impaired contractile function

Ejection Fraction of 55% The diagnosis of diastolic heart failure is based on the presence of heart failure symptoms with a normal ejection fraction, which is between 55% and 60%. In systolic heart failure, the ejection fraction is generally less than 45%. Diastolic failure is characterized by high filling pressures because of stiff ventricles. Systolic failure results from an inability of the heart to pump blood effectively, caused by impaired contractile function.

A nurse is caring for a patient who is admitted to the hospital with a diagnosis of new onset heart failure. The condition is not responding to usual care. The ejection fraction (EF) of this patient is 25%. Which diagnostic procedure will be prescribed to determine the cause of the heart failure? Electrocardiogram (ECG) Chest x-ray Cardiac catheterization Endomyocardial biopsy

Endomyocardial biopsy Endomyocardial biopsy is an investigation to find out the cause of new onset heart failure that is unresponsive to routine care. ECG, chest x-ray, and cardiac catheterization are common investigations performed for the diagnosis and prognosis of heart diseases.

A patient admitted to the health care facility with venous thromboembolism is prescribed unfractionated heparin, to be administered subcutaneously. Which interventions should the nurse follow during this procedure? Select all that apply. -Inject deep into abdominal fatty tissue. -Hold skinfold during injection. -Release skinfold after removing needle. -Avoid aspiration. -Rub site after injection.

Inject Deep into Abnormal Fatty tissue HOld skin during Injection Avoid Aspiration When administering unfractionated heparin subcutaneously, the nurse should inject deep into the abdominal fatty tissue, hold the skinfold during injection but release before removing the needle, and avoid aspiration. The nurse should not inject intramuscularly, rub the site after injection, or aspirate.

A patient experiences pain in the calf while exercising and reports that the pain disappears after a few minutes of resting. The nurse recognizes the finding as most consistent with: -Venous obstruction in the leg -Claudication resulting from venous abnormalities -Ischemia resulting from complete blockage of an artery -Ischemia resulting from partial blockage of an artery

Ischemia resulting from partial blockage of an artery Ischemia is a deficient supply of oxygenated arterial blood to tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise, when oxygen needs increase. Claudication does not result from venous abnormalities. Ischemic pain would not disappear with a complete blockage of an artery in the leg; the pain would be constant.

The nurse is caring for a patient after vein ligation surgery. What is an appropriate nursing intervention for this patient? -Maintain elastic compression stockings at all times. -Keep the legs elevated at 15 degrees. -Report any bruising and discoloration. -Ask patient to avoid deep breathing.

Keep the legs elevated at 15 degrees After vein ligation surgery, the nurse should ensure that the patient keeps his or her legs elevated at 15 degrees to reduce edema. Elastic compression stockings should be removed every eight hours for short periods and reapplied. Some bruising and discoloration are normal. The patient should be encouraged to breathe deeply to promote venous return.

The nurse is caring for a patient with post thrombotic syndrome in the health care facility. Lipodermatosclerosis is noted as one of the clinical signs for this patient. Which symptom is indicative of lipodermatosclerosis? -Leathery, brown-colored skin -Swollen leg -Blue-colored skin -Presence of severe pain

Leathery Brown-Colored Skin In lipodermatosclerosis, the skin on the lower leg is scarred and leathery, with brown discoloration.

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new prescription for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? -Spread the skin before inserting the needle. -Leave the air bubble in the prefilled syringe. -Use the back of the arm as the preferred site. -Sit the patient at a 30-degree angle before administration.

Leave the air bubble in the prefilled syringe The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and to avoid leaving medication in the needle track in the tissue. The skin is not spread before inserting the needle. The abdomen is the preferred site of administration. The patient does not sit at a 30-degree angle for administration.

A nurse is providing discharge teaching to a patient who had peripheral artery bypass surgery. Which statement by the patient indicates a need for further teaching? -"I need to call my health care provider if I have any foot problems." -"Gently clean the incision with mild soap and water then dry it well." -"My socks should be clean and preferably cotton or wool." -"It is important to immediately start regular daily exercise."

"Gently clean the incision with mild soap and water then dry it well." Peripheral artery bypass surgery routine postoperative wound care includes keeping the incision clean and dry and not disturbing the incision site. Cleaning the incision with soap and water increases the risk for incision site infection. Management of peripheral artery disease includes care for feet and legs. Thick or overgrown toenails and calluses are potentially serious and the health care provider (e.g., podiatrist) must be made aware of this. Also, wear clean cotton or wool socks. To promote increased circulation, participate in regular daily exercise.

While assessing a patient for orthopnea, what is an appropriate question for the nurse to ask? -"How many times do you get up at night to urinate?" -"How many pillows do you use for sleeping at night?" -"Do you get awakened by shortness of breath at night?" -"Are you comfortable while walking as well as talking at the same time?"

-"How many pillows do you use for sleeping at night?" Patients with heart failure often experience orthopnea. This refers to a condition in which patients may feel the need to sleep with their head elevated and use several pillows to sleep upright. When assessing a patient for nocturia, the nurse asks him how frequently he gets up at night to urinate. When assessing the patient for paroxysmal nocturnal dyspnea, the nurse asks if he wakes up at night due to shortness of breath at night. When checking for shortness of breath during daily activities, the nurse asks the patient whether he is comfortable while walking and talking at the same time.

A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? -Keep the patient on bed rest -Assist the patient with walking several times -Have the patient sit in the chair several times -Place the patient on her side with knees flexed

-Assist the patient with walking several times To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

An echocardiogram for a patient indicates enlarged ventricles of the heart. The nurse caring for the patient understands that this condition has occurred as a result of a chronic condition. What could be the cause of the cardiac dilation? -Elevated pressure in the ventricles -Increased muscle thickness -Increased release of catecholamine -Increased heart rate

-Elevated pressure in the ventricles Cardiac dilation is an enlargement of the heart chambers, usually the ventricles; it occurs when pressure in the heart chambers is elevated over time. Hypertrophy is an increase in the muscle mass and thickness of the cardiac wall in response to overwork and strain. When the sympathetic nervous system activation is increased, there is an increased release of catecholamines, which results in an increased heart rate.

The nurse finds that a patient with cardiovascular disorder has a red, itchy rash with flaky scales. Which instruction included in the dietary plan will be beneficial? -Include more flaxseed oil. -Include fortified and milled cereals. -Include meat, fish, and organ meats. -Include frozen and canned food products.

-Include meat, fish, and organ meats. The presence of a red, itchy rash with flaky scales indicates vitamin B6 deficiency. Foods such as meat and fish are rich in vitamin B6. Flaxseed oil helps maintain an alkaline body condition and inhibits folate absorption in the body. Vitamin B6 is found in the germ and aleuronic layers of grains. Milling results in loss of aleuronic layers and loss of vitamin B6. Food-processing methods, freezing, and canning result in loss of vitamin B6, so including frozen and canned food products in the patient's diet will not be beneficial.

A patient experiences pain in the calf while exercising and reports that the pain disappears after a few minutes of resting. The nurse recognizes the finding as most consistent with: -Venous obstruction in the leg -Claudication resulting from venous abnormalities -Ischemia resulting from complete blockage of an artery -Ischemia resulting from partial blockage of an artery

-Ischemia resulting from partial blockage of an artery Ischemia is a deficient supply of oxygenated arterial blood to tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise, when oxygen needs increase. Claudication does not result from venous abnormalities. Ischemic pain would not disappear with a complete blockage of an artery in the leg; the pain would be constant.

A patient is discharged from the hospital after undergoing femoral artery bypass surgery with synthetic graft replacement. The nurse reviews with the patient the signs and symptoms of acute arterial ischemia that occur with graft occlusion. Which is a sign of acute arterial occlusion? Select all that apply. -Pulse rate of 110 -Leg is pale and white -Severe pain in the lower leg -Oral temperature of 38.2 º C -No hair growth on lower legs -Redness along the surgical incision

Leg is pale and white, and severe pain in the lower leg Clinical signs and symptoms of acute arterial ischemia are the "six Ps": pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (leg is the temperature of the environment or cooler). A pale, white limb and severe pain are signs of acute arterial ischemia. A tachycardic heart rate of 110 and oral temperature of 38.2º C are consistent with an infection. No hair growth on legs occurs with chronic decreased circulation. A reddened incision is consistent with inflammation or infection.

A nurse is reviewing a patient's laboratory results: blood cholesterol level of 350 mg/dL; homocysteine level of 14 µmol/L; b-Type natriuretic peptide (BNP) of 90 pg/mL; Troponin I (cTnI) level of 0.3 ng/mL; myoglobin level of 16 mcg/L, and C-reactive protein of 3 mg/L. What should the nurse interpret from the lab reports? -The patient has had a myocardial infarction -The patient has a high risk of cardiovascular diseases -The patient has heart failure -The patient has pulmonary complications

-The patient has a high risk of cardiovascular diseases The patient has a high risk of developing cardiovascular disease as evident by the high cholesterol levels, the homocysteine levels, and the C-reactive protein level. High cholesterol levels directly impact the heart and the blood vessels. A high homocysteine level indicates amino acid production during protein catabolism. It can harm the endothelium. C-reactive protein is a marker of inflammation and its presence increases the risk of cardiac diseases. The patient has normal levels of troponin and myoglobin which are indicators of myocardial injury, therefore, the patient does not have myocardial infarction. The b-Type natriuretic peptide (BNP) level is normal, thus ruling out heart failure. A normal level of BNP also rules out pulmonary complications.

A nurse at the health care facility is caring for a patient on anticoagulant therapy for venous thromboembolism. Which interventions should the nurse perform for this patient? Select all that apply. -Monitor platelet count. -Use restraints if required -Use small-gauge needle for venipuncture. -Avoid manual pressure at venipuncture sites. -Monitor for decreased blood pressure or increased heart rate.

Monitor Platelet COunt Use small-gauge needle for venipuncture Monitor for decreased blood pressure or increased heart rate Nursing interventions for the patient taking anticoagulant therapy include evaluation of platelet count for signs of heparin-induced thrombocytopenia. The nurse should preferably use a small-gauge needle for venipuncture. The patient should be monitored for decreased blood pressure or increased heart rate, which are indicative of internal bleeding. Restraints should be avoided if possible, but if they are needed, the nurse should use soft, padded restraints. Manual pressure should be applied for 10 minutes or longer at venipuncture sites.

A patient with peripheral arterial disease (PAD) underwent atherectomy. The nurse routinely assesses the patient's color, temperature, and peripheral pulses and determines that all are within normal ranges. However, upon reassessment several hours after the surgery, the nurse finds that the peripheral pulses are absent. Which action by the nurse is most appropriate? -Notify the surgeon immediately -Consider it to be a normal finding -Perform ankle-brachial index measurement -Place the patient in a sitting position with legs dangling

Notify the Surgeon Immediately Postoperatively, loss of palpable pulse indicates obstruction in the blood vessel. The surgeon should be immediately notified for prompt treatment. It is not a normal finding in the post-operative period and immediate action needs to be taken to manage it.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the health care provider immediately to save the patient's limb? -Paralysis -Paresthesia -Crampiness -Referred pain

Paresthesia The health care provider must be notified immediately if any of the six Ps of acute arterial ischemia occurs to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are: paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign, indicating the death of nerves to the extremity. Cramping in the leg is more common with varicose veins. The pain is not referred.

The nurse is examining a female patient who experiences leg edema and pain. What assessment findings indicate to the nurse that the patient is at a high risk for venous thromboembolism (VTE)? Select all that apply. -The patient is addicted to tobacco -The patient has been taking oral contraceptives -The patient has been taking aspirin daily for one year -The patient has a family history of VTE -The patient underwent peripheral artery disease (PAD) surgery

-The patient is addicted to tobacco -The patient has been taking oral contraceptives -The patient has a family history of VTE -The patient underwent peripheral artery disease (PAD) surgery A 36-year old woman who uses oral contraceptives and tobacco is at high risk for VTE. These compounds may cause hypercoagulability and may activate the intrinsic coagulation pathway that leads to deep vein thrombosis and pulmonary embolism. The risk increases if the patient has a family history of VTE, as the patient may carry the mutated genes responsible for the disease. PAD surgery has no direct relation to this disease, but if the endothelium is damaged during the surgery, it can initiate the coagulation cascade. Some medications, such as corticosteroids, may stimulate thrombus formation, but aspirin has shown no such tendency.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? -Assess output for renal dysfunction -Use intravenous (IV) fluids to maintain adequate blood pressure (BP) -Use oral antihypertensives to maintain cardiac output -Maintain a low BP to prevent pressure on surgical site

-Use intravenous (IV) fluids to maintain adequate blood pressure (BP) The priority is to maintain an adequate BP (determined by the health care provider) to maintain graft patency. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses, resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used.

The nurse is monitoring a postoperative patient for venous thromboembolism (VTE). Which are probable clinical findings in a person with VTE? Select all that apply. -Venous distention -Vein appears as a palpable cord -Deep reddish color to the affected area -Itchiness and warmth over the affected area -Tenderness to pressure over the involved vein

-Venous distention -Deep reddish color to the affected area -Tenderness to pressure over the involved vein Clinical findings for VTE include tenderness to pressure over involved vein, induration of overlying muscle, venous distention, edema, possible mild to moderate pain, and a deep reddish color to area caused by venous congestion. Itchiness and cord-like texture are characteristics of superficial venous thrombosis.

A patient is diagnosed with an abdominal aortic aneurysm. The patient undergoes minimally invasive aneurysm repair with an endovascular graft and returns to the room on the unit after the procedure. Which is the priority action for the nurse at this time? -Assess the groin area bilaterally. -Measure the abdominal girth. -Determine when the patient last urinated. -Ask the patient to rate pain on a 0 to 10 scale.

Assess the groin area bilaterally. The endovascular graft is placed through the femoral arteries to the area of the aneurysm to prevent further expansion. The nurse first should inspect the groin areas, the femoral artery sites, for bleeding and hematoma. Measuring the abdominal girth, determining when the patient last urinated, and pain assessment are secondary in importance.

The P wave represents...

Atrial depolarization

Which sign or symptom is associated with acute dissection of the ascending aorta? -throbbing headache -Pulsating substernal mass -Chest pain described as ripping in nature -Cyanotic toes with palpable dorsalis pedis pulses

chest Pain Described as ripping in nature Dissection of the aorta occurs when a tear occurs in the intimal (inner) layer of the blood vessel and then blood flow separates the intimal and medial (middle) layers of the aorta. Chest pain that is ripping in nature occurs with dissection of the ascending aorta. The pain may radiate to the neck or shoulders, but does not involve a throbbing headache. There is not a mass with the dissection as there may be with an aortic aneurysm. Emboli from thrombus in an abdominal aneurysm cause cyanotic toes with palpable pedal pulses.