A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

Tachycardia

Rebound tenderness

Rigid abdomen

Elevated blood pressure

Answer and Explanation

Correct Answer : A,B,C

Tachycardia, or a rapid heartbeat, is a common response to the pain and stress associated with stomach perforation. The body’s sympathetic nervous system is activated in response to the pain and the potential shock state due to internal bleeding or infection, leading to an increased heart rate. Tachycardia is also a compensatory mechanism to maintain adequate blood flow and oxygen delivery to vital organs in the setting of decreased blood volume. A stomach perforation due to a peptic ulcer is a serious medical condition where an ulcer has led to a hole in the stomach lining. This can lead to the contents of the stomach spilling into the abdominal cavity, causing peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity).

Choice B: Rebound tenderness

Rebound tenderness is a clinical sign that indicates irritation of the peritoneum. When pressure is applied to the abdomen and then quickly released, the sudden movement of the peritoneal layers against each other produces sharp, rebound pain. This is a classic sign of peritonitis, which can occur with stomach perforation as gastric contents irritate the peritoneum. When assessing a client with a suspected stomach perforation due to a peptic ulcer, a nurse should expect to find signs of tachycardia, rebound tenderness, and a rigid abdomen. These findings are indicative of the body’s response to the acute abdominal condition and peritoneal irritation. It is crucial to recognize these signs promptly as stomach perforation is a medical emergency requiring immediate intervention.

Choice C: Rigid abdomen

A rigid abdomen is indicative of involuntary guarding, a reflex contraction of the abdominal muscles to protect inflamed organs within the abdomen. This rigidity is a sign of peritoneal irritation and is often present in cases of stomach perforation. The rigidity helps to immobilize the area, which may reduce pain but also serves as a clinical indicator of serious intra-abdominal pathology.

Choice D: Elevated blood pressure

Elevated blood pressure is not typically a direct result of stomach perforation. In fact, blood pressure may initially be normal or even low, depending on the body’s response to internal bleeding and the potential development of shock. However, pain and anxiety can cause a transient increase in blood pressure, but it is not a primary diagnostic criterion for stomach perforation.

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Correct Answer is C

Explanation

Choice A reason: Atropine is not typically used for the treatment of pulmonary embolism. It is an anticholinergic drug that is primarily used to treat bradycardia (slow heart rate) and as part of the management of organophosphate poisoning. It does not have a role in the management of pulmonary embolism, which requires anticoagulation to prevent further clot formation.

Choice B reason: Furosemide is a loop diuretic commonly used to treat fluid overload conditions such as heart failure or edema. While it can help relieve symptoms associated with fluid accumulation, it does not treat the underlying cause of a pulmonary embolism, which is a blood clot in the pulmonary arteries.

Choice C reason: Heparin is an anticoagulant medication that is commonly used in the initial treatment of pulmonary embolism. It works by preventing the formation of new blood clots and stopping existing clots from getting bigger. Heparin is often administered intravenously or subcutaneously and is a key component in the management of pulmonary embolism.

Choice D reason: Dexamethasone is a corticosteroid that is used to reduce inflammation in various conditions, such as allergic reactions, asthma, and certain types of arthritis. It is not used as a primary treatment for pulmonary embolism, as it does not have anticoagulant properties.

A. Hematemesis B. Abdominal bloating C. Epigastric discomfort D. Dyspepsia

Correct Answer is A

Explanation

Choice A reason: Hematemesis Hematemesis, or vomiting blood, is a serious symptom that usually indicates bleeding in the upper gastrointestinal tract. This could be due to a severe peptic ulcer, among other conditions1. The blood may appear red or black, and the condition can cause a person to go into hypovolemic shock, which can lead to organ failure and death if not treated immediately. Therefore, hematemesis should be identified as the priority symptom in this case. While all these symptoms can be associated with peptic ulcer disease, hematemesis is the most serious and should be prioritized due to the risk of significant blood loss and potential for hypovolemic shock.

Choice B reason: Abdominal bloating Abdominal bloating is a symptom that can be caused by various conditions, including indigestion, overeating, and certain medical conditions. While it can be uncomfortable, it is generally not as immediately life-threatening as hematemesis.

Choice C reason: Epigastric discomfort Epigastric discomfort refers to pain or discomfort in the upper abdomen, below the ribs. It can be caused by conditions such as acid reflux, GERD, overeating, lactose intolerance, and others. While it can be a symptom of a peptic ulcer, it is not typically as urgent as hematemesis.

Choice D reason: Dyspepsia Dyspepsia, also known as indigestion, can cause symptoms such as bloating, heartburn, and feeling full too quickly8910. It can be caused by a variety of factors, including certain foods, overeating, and medical conditions like GERD. While it can be a symptom of a peptic ulcer, it is generally not as immediately life-threatening as hematemesis.

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A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

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