An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first?
a. Measure the client's abdominal girth.
b. Assess for abdominal guarding or rigidity.
c. Check the client's hemoglobin and hematocrit.
d. Obtain the client's complete health history.
ANS: B
On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.
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