A client admitted to the emergency department with coffee-grounds emesis and melena develops sudden, severe upper abdominal pain and calls for the nurse. The client is doubled over in pain and is diaphoretic
The nurse suspects a perforated ulcer. The nurse should assess for which other signs or symptoms? A)
fever and respiratory depression
B)
rigid, boardlike abdomen
C)
bowel sounds increased in frequency and pitch
D)
diarrhea
B
Explanation:
A)
This would be indicative of peritonitis and would support suspicion of a perforated ulcer. An increased respiratory rate would be more likely. Option C would be indicative of a bowel obstruction. Diarrhea would not be suspected.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
B)
This would be indicative of peritonitis and would support suspicion of a perforated ulcer. An increased respiratory rate would be more likely. Option C would be indicative of a bowel obstruction. Diarrhea would not be suspected.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
C)
This would be indicative of peritonitis and would support suspicion of a perforated ulcer. An increased respiratory rate would be more likely. Option C would be indicative of a bowel obstruction. Diarrhea would not be suspected.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
D)
This would be indicative of peritonitis and would support suspicion of a perforated ulcer. An increased respiratory rate would be more likely. Option C would be indicative of a bowel obstruction. Diarrhea would not be suspected.
Analysis
Assessment
Physiological Integrity: Reduction of Risk Potential
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