Question

A client admitted to ED with coffee-grounds emesis and melena develops sudden, severe upper abd pain and calls for nurse. The client is doubled over in pain and is diaphoretic. The nurse suspects a perforated ulcer. The nurse should assess for:

a) Decreased bowel sounds
b) Hypertension
c) Increased abdominal distension
d) Rebound tenderness

Answer 1

In the case of a suspected perforated ulcer, the nurse should assess for decreased bowel sounds, increased abdominal distension, and rebound tenderness, which are indicative of peritonitis and require urgent medical intervention.

Step-by-step explanation:

When a client presents with symptoms such as coffee-grounds emesis and melena and then develops sudden severe upper abdominal pain and other symptoms like being diaphoretic, a perforated ulcer can indeed be suspected. Among the key signs a nurse should assess for in such a scenario are:

• Decreased bowel sounds: Perforation of an ulcer can significantly affect bowel motility, leading to reduced bowel sounds.
• Increased abdominal distension: Leakage of stomach or intestinal contents into the abdominal cavity can lead to distension.
• Rebound tenderness: This is a classic sign of peritonitis, which can occur due to the spillage of gastric contents into the peritoneal cavity from a perforated ulcer.

It's less likely that hypertension would be directly associated with perforated ulcer presentation. Adequate assessment can lead to a more accurate diagnosis and pave the way for essential emergency interventions such as surgery and administration of antibiotics for peritonitis, a potentially life-threatening condition arising from ulcer perforation.