A nurse in the emergency department is caring for a patient who reports severe abdominal pain in the left quadrant. The healthcare provider suspects a ruptured ectopic pregnancy.
What sign should the nurse look for that indicates the patient has blood in the peritoneum?

Choice A rationale

Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying

tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.

Choice B rationale

Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.

Choice C rationale

Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.

Choice D rationale

Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.

Choice A rationale

As an advocate, the nurse acts to protect the patient’s rights and helps them to speak for themselves. This includes supporting the patient’s decisions, even when these decisions might not be in line with the nurse’s personal beliefs.

Choice B rationale

As a manager, the nurse coordinates activities of members of the nursing staff in delivering nursing care, and oversight ensures that care is safe, effective, and patient-centered.

Choice C rationale

As a caregiver, the nurse assists patients with meeting their physical, psychological, and developmental needs. This role involves direct patient care activities.

Choice D rationale

As an educator, the nurse works to enhance patients’ knowledge about their health and care, promoting health behaviors and self-care skills.